Compositions, methods and uses for the treatment of diabetes and related conditions by controlling blood glucose level

ABSTRACT

The present invention relates to compositions and methods for controlling glycemia in a mammalian in need thereof. The present invention relates to compositions and methods for the treatment of diabetes and related disorders. More specifically, the present invention relates to novel therapies or combinatorial therapies for diabetes and related disorders, based on compositions controlling the blood glucose level.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a divisional of U.S. application Ser. No.14/698,920, filed Apr. 29, 2015, which is a continuation-in-part ofInternational Application No. PCT/EP2013/072728, filed Oct. 30, 2013,which claims priority from U.S. Provisional Application Ser. No.61/720,156, filed Oct. 30, 2012, now abandoned, the disclosures of whichare hereby incorporated by reference in their entirety, including allfigures, tables and amino acid or nucleic acid sequences.

FIELD OF THE INVENTION

The present invention relates to compositions and methods forcontrolling glycemia in a mammalian in need thereof. More specifically,the present invention relates to novel therapies or combinatorialtherapies of diabetes and related disorders, based on compositionscontrolling the blood glucose level.

BACKGROUND OF THE INVENTION

Diabetes mellitus refers to a group of metabolic diseases in whichpatients have high blood sugar levels. It is a major public healthproblem due to high number of affected patients since 171 million peopleworldwide, corresponding to 2.8% of the population in 2000, arediabetic. Diabetes is now considered an epidemic: the number of patientsshould almost double by 2030. There are mainly two types of diabetes.Type 1 diabetes is mainly characterized by insulin dependent patients,and is known to be autoimmune, sometimes triggered by infectiousfactors. It usually starts in patients younger than 30 and it accountsfor about 5-10% of all cases of diabetes [1]. Type 2 diabetes, mainlycharacterized by insulin independence, has a later onset than type 1diabetes and is therefore named adult-onset diabetes. It accounts forabout 90-95% of all diabetes cases. Many factors can potentially giverise to or exacerbate type 2 diabetes. These include hypertension,elevated cholesterol, metabolic syndrome and overweight/obesity. As anexample, approximately 90% of patients with type 2 diabetes areoverweight/obese [2]. Other forms of diabetes include gestationaldiabetes, congenital diabetes, cystic fibrosis-related diabetes, steroiddiabetes, and several forms of monogenic diabetes. Current treatmentsconsist of insulin administration for type 1 diabetes and/orglucose-lowering medications or insulin sensitizers for type 2 diabetes.Insulin is a hormone involved in the glucose homeostasis, together withglucagon. In response to rising levels of blood glucose, insulin isproduced by pancreatic beta cells located in the islets of Langerhans.Thus, glucose is taken up from the blood by hepatocytes, muscle cells,and adipocytes used either as an energy source or for storage asglycogen and triglycerides. It also inhibits lipolysis, preventing fattyacid release from fat tissues. On the contrary, low blood glucose levelsresult in both reduced production and release of insulin. Together withglucagon action, it results in glucose release into the bloodstream. Inpathological situations, either insulin production by beta-cells is notsufficient (type 1 diabetes) and/or cells respond poorly to it (insulinresistance; type 2 diabetes), leading to persistent high levels of bloodglucose. Precise mechanisms involved in these pathologies are not yetcompletely understood.

The decrease in insulin production characterizing type 1 diabetes is dueto the destruction of beta-cells by an autoimmune process that consistsof autoantibody production, activation of self-reactive lymphocytes andinfiltration of the pancreas to destroy beta-cells. Type 2 diabetesmellitus is considered to be a complex metabolic disorder. It resultsfrom the combination of impaired pancreatic insulin secretion due tobeta-cells dysfunction and insulin resistance as well as damagedglucagon secretion. Impairment of glucose-stimulated production ofinsulin involves a progressive loss of pancreatic beta-cells as well asa decline in islet cell function. Insulin resistance consists forexample of suppressed or reduced effects of insulin in peripheralorgans/tissues (liver, muscles and fat tissues) or enhanced lipolysis inadipocytes, leading to increased circulation of free fatty acids. Theseevents result in increased endogenous glucose production by the livertogether with decreased glucose uptake due to reduced insulin receptorexpression, defects in post-receptor actions of insulin [3], hepaticglucose overproduction or blocking of insulin-signaling pathways [4].Insulin resistance is a hallmark of a more complex syndrome, calledmetabolic syndrome, which is a grouping of risk factors for coronaryheart disease and diabetes mellitus including abdominal obesity,elevated triglyceride levels, decreased high-density lipoprotein levels,elevated blood pressure, and elevated fasting plasma glucose levels [5].75% of type 2 diabetes patients have metabolic syndrome.

Persistent high blood glucose leads to both acute and chroniccomplications that may be very disabling, even fatal for diabeticpatients, such as heart disease and stroke, which are the mostlife-threatening consequences of diabetes mellitus. Long-term persistentelevated blood glucose damages blood vessels, leading to microvascularand macrovascular angiopathy, which account for most of the increasedmorbidity and mortality associated with the disease. Microvascularcomplications are responsible for diabetic cardiomyopathy andnephropathy, both sometimes leading to organ failure, retinopathy, whichcan lead to severe vision loss, and neuropathy. Macrovascularcomplications rather concern cardiovascular impairments that areresponsible for coronary artery disease that in the end provokes anginaor myocardial infarction, diabetic myonecrosis, peripheral vasculardisease and stroke. Macrovascular complications are more common and upto 80% of patients with type 2 diabetes will develop or die of amacrovascular disease.

Unfortunately, existing treatments do not succeed in restoringnormoglycemia in the long term, since beta-cell function declines overtime [6]. Moreover, there is presently no single drug able to reverseall aspects of the disease.

Control of glycemia in type 1 diabetes is almost exclusively achievedwith injections of exogenous insulin, since patients no longer produceinsulin. Insulin may also be administered to type 2 diabetes patientswhen glucose-lowering drugs and diet fail to control glycemia [7]. It isnowadays more frequently administered to these patients, since it delaysdevelopment and progression of complications. Use of insulin, however,comprises side effects including hypoglycemia when dosage is notappropriate, increased risk of developing colorectal cancer [8] andgaining weight, which is not recommended for diabetic patients,particularly obese ones.

The progressive nature of type 2 diabetes implies that many patientswill eventually require a combination of antidiabetics, possiblytogether with insulin [9]. Antidiabetics have been developed in order tocounteract the main mechanisms involved in type 2 diabetes: insulinresistance (biguanides and thiazolidinediones) and insulin secretion(sulfonylureas, glinides, dipeptidylpeptidase-4 inhibitors, andglucagon-like peptide 1 receptor agonists), in addition to particularmechanisms dealing with delayed absorption of glucose by thegastrointestinal tract. However, most of these medications have beenshown to have deleterious side effects such as weight gain, peripheraledema or congestive heart failure and to loss in efficiency in a longterm use [9].

Despite the increasing number of therapeutic options related todiabetes, none is able to reverse all the aspects of the diseaseincluding progressive loss of beta cells function and the management ofall the complications. Thus, there is a need for alternative andimproved medications for the treatment of diabetes and relatedconditions.

SUMMARY OF INVENTION

The present invention provides novel compositions and methods fortreating diabetes and related disorders, particularly type 2 diabetes.

The present invention also provides compositions and methods tonormalize glycemia in a mammalian subject in need thereof.

The invention also relates to compositions and methods for controllingblood glucose levels in mammalian subjects, particularly in mammaliansubjects having diabetes or a related disorder.

The invention also relates to compositions and methods for increasing orstimulating glucose uptake in adipocytes and/or muscular cells inmammalian subjects, particularly in mammalian subjects having diabetesor a related disorder.

The invention also relates to compositions and methods for decreasinginsulin resistance in mammalian subjects, particularly in mammaliansubjects having type 2 diabetes or a related disorder.

The invention also relates to compositions and methods for decreasingapoptosis of pancreatic beta-cells in mammalian subjects, particularlyin mammalian subjects having diabetes or a related disorder.

The present invention discloses the identification and validation, bythe inventors, of drugs which, alone or in combination(s), effectivelyaffect either one or several relevant pathways involved in the controlof blood glucose levels and represent new and effective therapies forthe treatment of diabetes and related disorders. The invention thereforediscloses novel therapies of diabetes (type 1 or type 2) and relatedconditions, as well as novel drugs and drug combinations that areparticularly effective for such conditions. The invention is applicableto any mammalian, particularly human, subject. The invention isparticularly suited for treating type 2 diabetes or metabolic syndrome,which are associated with abnormally elevated blood glucose levels.Treatments according to the invention may be used in combination or inalternation with other therapies of such conditions.

An object of the invention relates more specifically to a compositioncomprising at least one, preferably at least two compound(s) selectedfrom acamprosate, almitrine, amlexanox, azelastine, baclofen,carbetapentane, cinacalcet, dexbrompheniramine, diethylcarbamazine,D-mannose, fenspiride, fexofenadine, ifenprodil, mexiletine,nicergoline, tolperisone, torasemide, triamterene, tolfenamic acid,piribedil, levosimendan, cimetidine, diprophylline, idebenone orrilmenidine, for use in the treatment of diabetes or a related disorder.

In a preferred embodiment, said at least one, preferably at least twocompound(s) is (are) selected from acamprosate, almitrine, azelastine,baclofen, carbetapentane, cinacalcet, dexbrompheniramine,diethylcarbamazine, D-mannose, fenspiride, ifenprodil, levosimendan,mexiletine, nicergoline, tolfenamic acid, tolperisone, torasemide, ortriamterene.

In another particular embodiment, the compound(s) is (are) selected fromalmitrine, azelastine, acamprosate, baclofen, carbetapentane,dexbrompheniramine, diethylcarbamazine, D-mannose, ifenprodil,mexiletine, nicergoline, or tolperisone.

A more particular object of the invention relates to a compositioncomprising ifenprodil or fenspiride, for use in the treatment ofdiabetes or a related disorder.

As illustrated in the examples, the above compounds provide substantialeffects when used individually and are further particularly effective incombinations. The examples indeed show that combinatorial therapies areeven more preferred to regulate blood glucose levels, in particularglucose uptake and glucose production, as well as to decrease insulinresistance, and provide the most efficient clinical benefit.

Accordingly, a further object of this invention relates to a compositioncomprising at least:

-   -   a first compound selected from acamprosate, almitrine,        azelastine, baclofen, carbetapentane, cinacalcet,        dexbrompheniramine, diethylcarbamazine, D-mannose, fenspiride,        ifenprodil, levosimendan, mexiletine, nicergoline, tolfenamic        acid, tolperisone, torasemide or triamterene, and    -   a second compound, distinct from the first compound, the second        compound being selected from acamprosate, almitrine, amlexanox,        azelastine, baclofen, carbetapentane, cinacalcet,        dexbrompheniramine, diethylcarbamazine, D-mannose, fenspiride,        fexofenadine, ifenprodil, mexiletine, nicergoline, tolperisone,        torasemide, triamterene, tolfenamic acid, piribedil,        levosimendan, cimetidine, diprophylline, idebenone or        rilmenidine, as well as to the use of such a composition in the        treatment of diabetes or a related disorder.

An object of this invention relates to a composition comprisingfenspiride or ifenprodil, and at least one distinct compound selectedfrom acamprosate, almitrine, amlexanox, azelastine, baclofen,carbetapentane, cinacalcet, dexbrompheniramine, diethylcarbamazine,D-mannose, fenspiride, fexofenadine, ifenprodil, mexiletine,nicergoline, tolperisone, torasemide, triamterene, tolfenamic acid,piribedil, levosimendan, cimetidine, diprophylline, idebenone orrilmenidine, as well as to the use of such a composition in thetreatment of diabetes or a related disorder.

Another object of the invention relates to a composition comprising atleast two compounds selected from acamprosate, almitrine, amlexanox,azelastine, baclofen, carbetapentane, cinacalcet, dexbrompheniramine,diethylcarbamazine, D-mannose, fenspiride, fexofenadine, ifenprodil,mexiletine, nicergoline, tolperisone, torasemide, triamterene,tolfenamic acid, piribedil, levosimendan, cimetidine, diprophylline,idebenone or rilmenidine, as well as to the use of such compositions inthe treatment of diabetes or a related disorder in a mammalian in needthereof.

The at least two compounds are more preferably selected from selectedfrom acamprosate, almitrine, azelastine, baclofen, carbetapentane,cinacalcet, dexbrompheniramine, diethylcarbamazine, D-mannose,fenspiride, ifenprodil, levosimendan, mexiletine, nicergoline,tolfenamic acid, tolperisone, torasemide or triamterene.

A particular object of this invention consequently related to acomposition comprising fenspiride or ifenprodil, and at least onedistinct compound selected from acamprosate, almitrine, azelastine,baclofen, carbetapentane, cinacalcet, dexbrompheniramine,diethylcarbamazine, D-mannose, fenspiride, ifenprodil, levosimendan,mexiletine, nicergoline, tolfenamic acid, tolperisone, torasemide ortriamterene for use in the treatment of diabetes or a related disorderin a mammalian in need thereof.

Drug compositions of this invention may also be used in furthercombination with other anti-diabetic agents or treatments in orderprovide improved clinical effects and/or to alleviate potential sideeffects of such anti-diabetic drugs or treatments.

Consequently, a further object of this invention relates to compositionscomprising:

-   -   a compound selected from acamprosate, almitrine, azelastine,        baclofen, carbetapentane, cinacalcet, dexbrompheniramine,        diethylcarbamazine, D-mannose, fenspiride, ifenprodil,        levosimendan, mexiletine, nicergoline, tolfenamic acid,        tolperisone, torasemide or triamterene; and    -   a compound selected from the group consisting of acarbose,        acetohexamide, alogliptin, berberine, bezafibrate,        bromocriptine, buformin, carbutamide, chlorpropamide, chromium        picolinate, ciprofibrate, clofibrate, colesevelam,        dexfenfluramine, dutogliptin, exenatide, fenofibrate,        gemfibrozil, gemigliptin, glibenclamide, glibornuride,        glicetanile, gliclazide, glimepiride, glipizide, gliquidone,        glisentide, glyclopyramide, imidapril, insulin, inulin, lipoic        acid, linagliptin, liraglutide, mecobalamin, metformin,        miglitol, mitiglinide, nateglinide, orlistat, phenformin,        pioglitazone, pramlintide, repaglinide, rosiglitazone,        saxagliptin, sitagliptin, tolazamide, tolbutamide, vildagliptin        and voglibose; as well as to the use of such compositions in the        treatment of diabetes or a related disorder in a mammalian in        need thereof.

An even more preferred object of this invention relates to compositionscomprising a compound selected from the group consisting of acamprosate,almitrine, azelastine, baclofen, carbetapentane, cinacalcet,dexbrompheniramine, diethylcarbamazine, D-mannose, fenspiride,ifenprodil, levosimendan, mexiletine, nicergoline, tolfenamic acid,tolperisone, torasemide or triamterene in combination with metformin, aswell as to the use of such compositions in the treatment of diabetes ora related disorder in a mammalian subject in need thereof.

The invention also relates to pharmaceutical compositions comprising adrug or drug combination as disclosed above. The pharmaceuticalcompositions of the invention typically comprise one or severalpharmaceutically acceptable excipients or carriers. Also, thecompound(s) in the compositions of the invention may be used as such orin the form of a salt, hydrate, ester, ether, acid, amide, racemate, orisomer. They may also be in the form of sustained-release formulations.Prodrugs or metabolites of the compound(s) may be used as well.

In an embodiment the invention relates to a composition comprising acombination selected from:

-   -   ifenprodil and acamprosate,    -   ifenprodil and baclofen,    -   baclofen and acamprosate,    -   mexiletine and cinacalcet,    -   mexiletine and torasemide,    -   sulfisoxazole and torasemide,    -   azelastine and nicergoline,    -   idebenone and nicergoline,    -   carbetapentane and nicergoline,    -   almitrine and nicergoline,    -   cimetidine and nicergoline,    -   diethylcarbamazine and nicergoline,    -   ifenprodil and nicergoline,    -   azelastine and idebenone,    -   acamprosate and nicergoline,    -   azelastine and carbetapentane,    -   azelastine and almitrine,    -   idebenone and carbetapentane,    -   idebenone and almitrine,    -   triamterene and nicergoline,    -   D-mannose and nicergoline,    -   idebenone and diethylcarbamazine,    -   ifenprodil and fenspiride,    -   ifenprodil and tolfenamic acid,    -   ifenprodil and torasemide,    -   ifenprodil and triamterene,    -   fenspiride and torasemide,    -   fenspiride and triamterene,    -   fenspiride and tolfenamic acid,    -   torasemide and tolfenamic acid,    -   torasemide and triamterene,    -   tolfenamic acid and triamterene, or    -   D-mannose and baclofen,        as well as to the use of such composition in the treatment of        diabetes or a related disorder in a mammalian in need thereof.

In another embodiment the invention relates to a combination ofmetformin with at least one of the above combination of compounds, aswell as its use in the treatment of diabetes or a related disorder in amammalian in need thereof.

As will be further disclosed in the present application, the compoundsin a composition or combinatorial therapy according to the invention maybe formulated or administered to the subject together, separately orsequentially, possibly through different routes and protocols. In apreferred embodiment, compositions of the invention are administeredrepeatedly to the subject.

The invention also relates to methods of treating diabetes or a relateddisorder, the methods comprising administering to a subject in needthereof a drug or drug(s) composition as disclosed above. In aparticular embodiment, the methods further comprise a step of measuringthe blood glucose level in a blood sample from the mammalian subject,either before or after drug(s) administration.

A further object of this invention relates to a method of treatingdiabetes or a related disorder, the method comprising simultaneously,separately or sequentially administering to a subject in need thereof adrug combination as disclosed above.

A further object of this invention relates to the use of theabove-described compositions for the manufacture of a medicament for thetreatment of diabetes or a related disorder.

The invention may be used in any mammalian subject, particularly a humansubject.

BRIEF DESCRIPTION OF THE FIGURES

Unless otherwise specified, tested drugs induce an effect significantlydifferent from reference (t-test: * p<0.05. ** p<0.01; *** p<0.001).

FIG. 1: Effect of D-mannose pre-treatment against apoptosis of betacells (optical density). The apoptosis is significantly prevented byD-mannose at doses as low as 10 nM (129%).

FIG. 2: Effect of triamterene short-term pre-treatment on insulinsecretion in INS-1 cells. The insulin secretion is significantlyenhanced by triamterene (+37%).

FIG. 3: Effect of cinacalcet long-term pre-treatment on insulinsecretion in INS-1 cells. The insulin secretion is significantlyenhanced by cinacalcet at doses as low as 1 μM (+55%).

FIG. 4: Effect of acamprosate short-term pre-treatment on glucose uptakein H-2 Kb cells. The glucose uptake is significantly enhanced byacamprosate at doses as low as 0.1 μM (+45%).

FIG. 5: Effect of almitrine short-term pre-treatment on glucose uptakein H-2 Kb cells. The glucose uptake is significantly enhanced byalmitrine at doses as low as 1 μM (+80%).

FIG. 6: Effect of nicergoline long-term pre-treatment on glucose uptakein H-2 Kb cells. The glucose uptake is significantly enhanced bynicergoline (+28%).

FIG. 7: Effect of carbetapentane short-term pre-treatment on glucoseuptake in 3T3-L1 cells. The glucose uptake is significantly enhanced bycarbetapentane at doses as low as 100 nM (+58%).

FIG. 8: Effect of almitrine long-term pre-treatment on glucose uptake in3T3-L1 cells. The glucose uptake is significantly enhanced by almitrineat doses as low as 1 μM (+69%).

FIG. 9: Effect of D-mannose short-term pre-treatment on glucoseproduction by hepatic cells. The glucose production is significantlyreduced by D-mannose (−22%).

FIG. 10: Effect of ifenprodil long-term pre-treatment on glucoseproduction by hepatic cells. The glucose production is significantlyreduced by ifenprodil at doses as low as 10 nM (−22%).

FIG. 11: Effect of azelastine long-term pre-treatment on glucoseproduction by hepatic cells. The glucose production is significantlyreduced by azelastine (−36%).

FIG. 12: Effect of piribedil short-term pre-treatment on glucose uptakein 3T3-L1 cells. The glucose uptake is significantly enhanced bypiribedil at doses as low as 10 nM (+68%).

FIG. 13: Effect of torasemide pre-treatment on glucose uptake in humanprimary diabetic myotubes. The glucose uptake is significantly enhancedat doses as low as 0.01 μM, 0.1 μM and 1 μM (+24%, +18% and +14%,respectively).

FIG. 14: Effect of fenspiride pre-treatment on glucose uptake indiabetic myotubes derived from a diabetic patient. The glucose uptake issignificantly enhanced at doses as low as 0.01 μM, 0.1 μM and 1 μM(+34%, +30% and +27%, respectively).

FIG. 15: Effect of tolfenamic acid pre-treatment on glucose uptake inhuman primary myotubes derived from a diabetic patient. The glucoseuptake is significantly enhanced at doses as low as 0.01 μM, 0.1 μM and1 μM (+13%, +13% and +12%, respectively).

FIG. 16: Effect of ifenprodil pre-treatment on glucose uptake in humanprimary diabetic myotubes. The glucose uptake is enhanced at doses aslow as 0.01 μM (+48%).

FIG. 17: Effect of triamterene pre-treatment on glucose uptake in humanprimary diabetic myotubes. The glucose uptake is significantly enhancedat doses as low as 0.01 μM (+13%).

FIG. 18: Effect of torasemide pre-treatment on glucose uptake by 3T3L1differentiated adipocytes, under TNF-α induced insulin resistanceconditions. The glucose uptake is significantly enhanced at doses as lowas 0.37 nM, 1 nM and 3.3 nM (+121%, +123% and +129%, respectively) whencompared to non-treated insulin-resistant cells (TNFα).

FIG. 19: Effect of ifenprodil pre-treatment on glucose uptake by 3T3L1differentiated adipocytes, under TNF-α induced insulin resistanceconditions. The glucose uptake is significantly enhanced at doses as lowas 1 μM (+140%) when compared to non-treated insulin-resistant cells(TNFα).

FIG. 20: Effect of fenspiride pre-treatment on glucose uptake by 3T3L1differentiated adipocytes, under TNF-α induced insulin resistanceconditions. The glucose uptake is significantly enhanced at doses as lowas 1 nM (+130%) when compared to non-treated insulin-resistant cells(TNFα).

FIG. 21: Effect of tolfenamic acid pre-treatment on glucose uptake by3T3L1 differentiated adipocytes, under TNF-α-induced insulin resistanceconditions. The glucose uptake is significantly enhanced at doses as lowas 10 nM (+127%) when compared to non-treated insulin-resistant cells(TNFα).

FIG. 22: Effect of baclofen—acamprosate combination on plasma CRPconcentration in ZDF male rats after a 4-week treatment. The CRPconcentration is significantly reduced by the baclofen—acamprosatecombination in treated ZDF rats when compared to non-treated ZDF rats.

FIG. 23: Effect of D-mannose—baclofen—metformin combination(respectively, 5 mg/kg and 2 mg/kg bid, and 150 mg/kg once a day)short-term treatment on glucose homeostasis in db/db mice. Fastingglycemia (mg/dL) is significantly decreased in treated db/db mice whencompared with non-treated db/db mice.

FIG. 24: Effect of pre-treatment with the combination of fenspiride andifenprodil on glucose uptake by 3T3L1 differentiated adipocytes, underTNF-α induced insulin resistance conditions. The glucose uptake ofinsulin resistant cells is significantly enhanced in the cellspretreated with the drugs combined at a dose as low as 3.3 nM (+124%)when compared to non-treated insulin-resistant cells (TNFα). Nosignificant effect is noticed in the cells pretreated with the drugsused individually (Dunnett's test, **p<0.01).

FIG. 25: Effect of pre-treatment with the combination of fenspiride andtriamterene on glucose uptake by 3T3L1 differentiated adipocytes, underTNF-α induced insulin resistance conditions. The glucose uptake ofinsulin-resistant cells is significantly enhanced in the cellspretreated with the drugs combined at a dose as low as 10 nM (+116%)when compared to non-treated insulin-resistant cells (TNFα). Nosignificant effect is noticed in the cells pretreated with the drugsused individually (Dunnett's test, *p<0.05).

FIG. 26: Effect of pre-treatment with the combination of fenspiride andtolfenamic acid on glucose uptake by 3T3L1 differentiated adipocytes,under TNF-α induced insulin resistance conditions. The glucose uptake ofinsulin-resistant cells is significantly enhanced in the cellspretreated with the drugs combined at a dose as low as 10 nM (+115%)when compared to non-treated insulin-resistant cells (TNFα). Nosignificant effect is noticed in the cells pretreated with the drugsused individually (Dunnett's test, *p<0.05).

FIG. 27: Effect of pre-treatment with the combination of ifenprodil andtolfenamic acid on glucose uptake by 3T3L1 differentiated adipocytes,under TNF-α induced insulin resistance conditions. The glucose uptake ofinsulin resistant cells is significantly enhanced in the cellspretreated with the drugs combined at a dose as low as 3.3 nM (+124%)when compared to non-treated insulin-resistant cells (TNFα). Nosignificant effect is noticed in the cells pretreated with the drugsused individually (Dunnett's test, *p<0.05).

FIG. 28: Enhancing effect of fenspiride on metformin treatment ofinsulin resistance in the model of glucose uptake by 3T3L1differentiated adipocytes, under TNF-α induced insulin resistanceconditions. The glucose uptake of insulin resistant cells issignificantly enhanced in the cells pretreated with the combination ofthe two drugs (fenspiride 3.3 nM and metformin 100 μM) (+136%) whencompared to non-treated insulin-resistant cells (TNFα). No significanteffect is noticed for the drugs when used alone at the sameconcentrations (Dunnett's test, *p<0.05).

FIG. 29: Enhancing effect of ifenprodil on metformin treatment ofinsulin resistance in the model of glucose uptake by 3T3L1differentiated adipocytes, under TNF-α-induced insulin resistanceconditions. The glucose uptake of insulin resistant cells issignificantly enhanced in the cells pretreated with the combination ofthe two drugs (ifenprodil 3.3 nM and metformin 100 μM) (+126%) whencompared to non-treated insulin resistant cells (TNFα). No significanteffect is noticed for the drugs when used alone at the sameconcentrations.

DETAILED DESCRIPTION OF THE INVENTION

The present invention provides new therapeutic approaches forcontrolling blood glucose level. The invention discloses novel drugs,drug combinations and methods which allow an effective control of bloodglucose level and may be used for patient treatment.

The invention therefore relates to compositions and methods for thetreatment of diabetes and related disorders.

Definitions

Within the context of the invention, the term “treatment” includespreventive or curative treatment. The term “treatment” designates inparticular the correction, retardation, or reduction of an impairedglucose homeostasis. The level of glucose in the blood fluctuatesthroughout the day. Glucose levels are usually lower in the morning,before the first meal of the day and rise after meals for some hours.Consequently, the term “treatment” includes the control of blood glucoselevel by increasing or decreasing blood glucose level depending on thecondition of the mammalian subject and the time of day in order to reacha normal glucose level. The term “treatment” more particularly includesa temporary or persistent reduction of blood glucose level in a subjecthaving diabetes or a related disorder. The term “treatment” alsodesignates an improvement in insulin release (e.g., by pancreaticβ-cells), glucagon release (e.g., by pancreatic α-cells), glucoseutilization and/or uptake (e.g., capture of glucose by muscle cells oradipocytes), and/or hepatic neoglucogenesis.

Within the context of the invention, the terms “controlling the bloodglucose level” or “the control of blood glucose level” refer to thenormalization or regulation of the blood or plasma glucose level in amammalian subject having abnormal levels (i.e., levels that are below orabove a known reference, median, or average value for a correspondingmammalian subject with a normal glucose homeostasis).

The term “diabetes” refers herein to a group of metabolic diseases inwhich patients have high blood glucose levels, including Type 1diabetes, Type 2 diabetes, gestational diabetes, congenital diabetes,cystic fibrosis-related diabetes, steroid diabetes, and several forms ofmonogenic diabetes.

The term “related disorder” designates any disease associated with ablood or plasma glucose level outside the normal range, preferablyhyperglycemia. Consequently, the term “related disorder” includesimpaired glucose tolerance (IGT), impaired fasting glucose (IFG),insulin resistance, metabolic syndrome, postprandial hyperglycemia andoverweight/obesity. Such related disorders can also be characterized byan abnormal blood and/or plasma insulin level.

The terms “combination”, “combinatorial therapy” or “combinatorytreatment” designate a treatment wherein at least two compounds areco-administered to a subject to cause a biological effect. In a combinedtherapy according to this invention, the at least two drugs may beadministered together or separately, at the same time or sequentially.Simultaneous administration is not required, as long as the drugsproduce a combined or synergistic effect in the organism to improve thepatient's condition. Also, the at least two drugs may be administeredthrough different routes and protocols. As a result, although they maybe formulated together, the drugs of a combination may also beformulated separately.

Within the context of the invention, the terms “compound” or “drug” asidentified by its name or CAS number are meant to designate the chemicalcompound as specifically named or identified with its corresponding CASnumber, as well as any pharmaceutically acceptable salt, hydrate,isomer, racemate, conjugate or derivative thereof, of any chemicalpurity.

The term “derivative” includes any functionally and structurally relatedcompound, such as acid derivatives, amide derivatives, esterderivatives, ether derivatives, prodrugs and metabolites.

The term “prodrug” as used herein refers to any derivative (orprecursor) of a compound which, when administered to a biological system(e.g., a human organism), generates said compound as a result of, e.g.,spontaneous chemical reaction(s), enzyme catalyzed chemical reaction(s),and/or metabolic chemical reaction(s). Prodrugs typically have thestructure X-drug wherein X is an inert carrier moiety and drug is theactive compound. Usually, the prodrug is devoid of activity or lessactive than the drug and the drug is released from the carrier in vivo.Prodrugs are usually inactive or less active than the resulting drug andcan be used, for example, to improve the physicochemical properties ofthe drug, to target the drug to a specific tissue, to improve thepharmacokinetic and pharmacodynamic properties of the drug and/or toreduce undesirable side effects. Some of the common functional groupsthat are amenable to prodrug design include, but are not limited to,carboxylic, hydroxyl, amine, phosphate/phosphonate and carbonyl groups.Prodrugs typically produced via the modification of these groupsinclude, but are not limited to, esters, carbonates, carbamates, amidesand phosphates. Specific technical guidance for the selection ofsuitable prodrugs is general common knowledge [11-15]. Furthermore, thepreparation of prodrugs may be performed by conventional methods knownby those skilled in the art. Methods which can be used to synthesizeprodrugs are described in numerous reviews on the subject [12; 16-21].

The term “metabolite” of a drug as used herein refers to a moleculewhich results from the (biochemical) modification(s) or processing ofsaid drug after administration to an organism, usually throughspecialized enzymatic systems, and which displays or retains abiological activity of the drug. Metabolites have been disclosed asbeing responsible for much of the therapeutic action of the parent drug.

The term “salt” refers to a pharmaceutically acceptable and relativelynon-toxic inorganic or organic acid or basic addition salt of a compoundof the present invention. Pharmaceutical salt formation typicallyconsists of pairing an acidic, basic or zwitterionic drug molecule witha counterion to create a salt version of the drug. A wide variety ofchemical species can be used in neutralization reactions. Though mostsalts of a given active principle are bioequivalents, some may have,among other properties, increased solubility or bioavailability. Saltselection is now a common standard operation in the process of drugdevelopment as taught by H. Stahl and C. G. Wermuth in their handbook[22].

In a preferred embodiment, the designation of a compound is meant todesignate the compound per se, as well as any pharmaceuticallyacceptable salt, hydrate, isomer, racemate, ester or ether thereof.

In a more preferred embodiment, the designation of a compound is meantto designate the compound as specifically designated per se, as well asany pharmaceutically acceptable salt thereof.

In a particular embodiment, a sustained-release formulation of thecompound is used.

Compositions and Methods for Treating Diabetes and Related Disorders

By a comprehensive integration of experimental data covering results ofcell biology studies, expression profiling experiments and geneticassociation studies, the inventors have been able to select a smallnumber of drugs which, alone and/or in combination(s), effectively alterrelevant pathways for the control of glycemia and represent newtherapeutic approaches for treating diabetes and related disorders.These drugs or combinations may be used to normalize blood glucose levelby acting, e.g., on insulin release, glucagon release, glucoseutilization and/or glucose production, and offer novel potent therapiesfor diabetes and related disorders. As disclosed in the examples, thesedrugs and combinations have a strong effect on diabetes' relevantfunctions: they are involved in the protection of beta cells againstapoptosis, the increase of glucose uptake in muscular tissues andadipocytes, the increase of insulin secretion by the pancreatic β cellsand/or the control of glucose production in hepatic tissues.

These drugs and combinations therefore represent new therapeuticapproaches for the control of blood glucose level in a mammalian in needthereof. They also represent new therapeutic approaches for thetreatment of diabetes or related disorders in a mammalian in needthereof.

In this regard, an object of this invention relates to compositionscomprising at least one compound selected from the group consisting ofacamprosate, amlexanox, almitrine, azelastine, baclofen, carbetapentane,cinacalcet, dexbrompheniramine, diethylcarbamazine, D-mannose,fenspiride, fexofenadine, ifenprodil, mexiletine, nicergoline,tolperisone, torasemide, triamterene, tolfenamic acid, piribedil,levosimendan, cimetidine, diprophylline, idebenone and rilmenidine, foruse in the treatment of diabetes or a related disorder in a mammalian inneed thereof.

The invention also relates to the use of at least one compound as listedabove for the manufacture of a medicament for treating diabetes or arelated disorder in a mammalian in need thereof.

The invention also relates to a method for treating diabetes or arelated disorder in a mammalian in need thereof, comprisingadministering to the mammalian at least one compound as listed above.

Illustrative CAS numbers for each of the selected compounds are providedin Table 1 below:

TABLE 1 Drug Name CAS number acamprosate 77337-76-9; 77337-73-6almitrine 27469-53-0; 29608-49-9 amlexanox 68302-57-8 azelastine58581-89-8; 79307-93-0 baclofen 1134-47-0; 66514-99-6; 69308-37-8;70206-22-3; 63701-56-4; 63701-55-3 carbetapentane 77-23-6; 23142-01-0;1045-21-2 cimetidine 51481-61-9; 70059-30-2 cinacalcet 226256-56-0;364782-34-3 dexbrompheniramine 86-22-6; 980-71-2; 2391-03-9diethylcarbamazine 90-89-1; 1642-54-2 diprophylline 479-18-5 D-mannose10030-80-5; 3458-28-4 fenspiride 5053-06-5; 5053-08-7 fexofenadine83799-24-0; 138452-21-8; 153439-40-8; 139965-10-9; 139965-11-0 idebenone58186-27-9 ifenprodil 23210-56-2; 23210-58-4 levosimendan 141505-33-1mexiletine 5370-01-4; 31828-71-4 nicergoline 27848-84-6 piribedil3605-01-4 rilmenidine 54187-04-1; 85409-38-7 tolfenamic acid 13710-19-5tolperisone 728-88-1; 3644-61-9 torasemide 56211-40-6; 72810-59-4triamterene 396-01-0

As mentioned in the examples, the above compounds, when testedindividually, are active to improve glucose levels by altering distinctimportant pathways of glucose homeostasis.

Furthermore, the inventors have surprisingly found that acamprosate,almitrine, azelastine, baclofen, carbetapentane, cinacalcet,dexbrompheniramine, diethylcarbamazine, D-mannose, fenspiride,ifenprodil, levosimendan, mexiletine, nicergoline, tolfenamic acid,tolperisone, torasemide and triamterene are particularly efficient inprotecting beta cells against apoptosis, improving the glucose uptake bymuscular tissues and/or the release of insulin. Such compounds thereforerepresent the most preferred embodiment for use in the presentinvention.

Consequently, the compositions of the invention may comprise 1, 2, 3, 4or 5 distinct above drugs, more preferably 2, 3 or 4 distinct drugs forcombinatorial treatment of diabetes or a related disorder in a subjectin need thereof. Furthermore, the above drug compositions may also beused in further combination with one or several additional drugs ortreatments beneficial to subjects suffering from diabetes or a relateddisorder.

In this regard, a particular object of the invention relates to acomposition for use in the treatment of diabetes or a related disorder,the composition comprising a compound selected from acamprosate,almitrine, azelastine, baclofen, carbetapentane, cinacalcet,dexbrompheniramine, diethylcarbamazine, D-mannose, fenspiride,ifenprodil, levosimendan, mexiletine, nicergoline, tolfenamic acid,tolperisone, torasemide or triamterene.

The above molecules are preferably used in combination therapies toprovide the most efficient clinical benefit. Drug combinations areparticularly advantageous because they can affect different pathways andthus are more effective. Also, because of their efficacy and mode ofaction, the drug combinations can be used at low dosages, which is afurther very substantial advantage. Thus, most preferred drugcompositions comprise 2, 3, 4 or 5 distinct drugs, even more preferably2, 3 or 4, for combinatorial treatment of diabetes or a related disorderin a subject in need thereof. In a preferred embodiment, the drugs ofthe invention are used in combination(s) for combined, separate orsequential administration, in order to provide the most effectiveeffect.

In this regard, a preferred object of this invention relates tocompositions comprising a combination of at least two compounds chosenfrom the group consisting of acamprosate, almitrine, amlexanox,azelastine, baclofen, carbetapentane, cinacalcet, dexbromopheniramine,diethylcarbamazine, D-mannose, fenspiride, fexofenadine, ifenprodil,mexiletine, nicergoline, tolperisone, torasemide, triamterene,tolfenamic acid, piribedil, levosimendan, cimetidine, diprophylline,idebenone and rilmenidine, as well as to the use of such compositions inthe treatment of diabetes or a related disorder in a mammalian in needthereof.

A more preferred object of this invention relates to compositionscomprising a combination of at least two compounds selected from thegroup consisting of acamprosate, almitrine, azelastine, baclofen,carbetapentane, cinacalcet, dexbrompheniramine, diethylcarbamazine,D-mannose, fenspiride, ifenprodil, levosimendan, mexiletine,nicergoline, tolfenamic acid, tolperisone, torasemide and triamterene,as well as to the use of such compositions in the treatment of diabetesor a related disorder in a mammalian in need thereof.

A further object of this invention relates to a composition comprising:

-   -   at least one compound selected from acamprosate, almitrine,        azelastine, baclofen, carbetapentane, cinacalcet,        dexbrompheniramine, diethylcarbamazine, D-mannose, fenspiride,        ifenprodil, levosimendan, mexiletine, nicergoline, tolfenamic        acid, tolperisone, torasemide or triamterene, and    -   at least one distinct compound selected from acamprosate,        almitrine, amlexanox, azelastine, baclofen, carbetapentane,        cinacalcet, dexbrompheniramine, diethylcarbamazine, D-mannose,        fenspiride, fexofenadine, ifenprodil, mexiletine, nicergoline,        tolperisone, torasemide, triamterene, tolfenamic acid,        piribedil, levosimendan, cimetidine, diprophylline, idebenone or        rilmenidine,

as well as to the use of such a composition in the treatment of diabetesor a related disorder.

Another object of this invention relates to compositions comprising (i)ifenprodil and (ii) a compound selected from the group consisting ofacamprosate, almitrine, amlexanox, azelastine, baclofen, carbetapentane,cinacalcet, dexbrompheniramine, diethylcarbamazine, D-mannose,fenspiride, fexofenadine, mexiletine, nicergoline, tolperisone,torasemide, triamterene, tolfenamic acid, piribedil, levosimendan,cimetidine, diprophylline, idebenone or rilmenidine, as well as to theuse of such composition in the treatment of diabetes or a relateddisorder in a mammalian in need thereof.

A further object of this invention relates to compositions comprising(i) acamprosate and (ii) a compound selected from the group consistingof almitrine, amlexanox, azelastine, baclofen, carbetapentane,cinacalcet, dexbrompheniramine, diethylcarbamazine, D-mannose,fenspiride, fexofenadine, ifenprodil, mexiletine, nicergoline,tolperisone, torasemide, triamterene, tolfenamic acid, piribedil,levosimendan, cimetidine, diprophylline, idebenone or rilmenidine, aswell as to the use of such composition in the treatment of diabetes or arelated disorder in a mammalian in need thereof.

A particular object of this invention relates to compositions comprising(i) azelastine and (ii) a compound selected from the group consisting ofacamprosate, almitrine, amlexanox, baclofen, carbetapentane, cinacalcet,dexbrompheniramine, diethylcarbamazine, D-mannose, fenspiride,fexofenadine, ifenprodil, mexiletine, nicergoline, tolperisone,torasemide, triamterene, tolfenamic acid, piribedil, levosimendan,cimetidine, diprophylline, idebenone or rilmenidine, as well as to theuse of such composition in the treatment of diabetes or a relateddisorder in a mammalian in need thereof.

Another particular object of this invention relates to compositionscomprising (i) torasemide and (ii) a compound selected from the groupconsisting of acamprosate, almitrine, amlexanox, azelastine, baclofen,carbetapentane, cinacalcet, dexbrompheniramine, diethylcarbamazine,D-mannose, fenspiride, fexofenadine, ifenprodil, mexiletine,nicergoline, tolperisone, triamterene, tolfenamic acid, piribedil,levosimendan, cimetidine, diprophylline, idebenone or rilmenidine, aswell as to the use of such composition in the treatment of diabetes or arelated disorder in a mammalian in need thereof.

An object of this invention relates to compositions comprising (i)fenspiride and (ii) a compound selected from the group consisting ofacamprosate, almitrine, amlexanox, azelastine, baclofen, carbetapentane,cinacalcet, dexbrompheniramine, diethylcarbamazine, D-mannose,fexofenadine, ifenprodil, mexiletine, nicergoline, tolperisone,torasemide, triamterene, tolfenamic acid, piribedil, levosimendan,cimetidine, diprophylline, idebenone or rilmenidine, as well as to theuse of such composition in the treatment of diabetes or a relateddisorder in a mammalian in need thereof.

A particular object of this invention relates to compositions comprising(i) tolfenamic acid and (ii) a compound selected from the groupconsisting of acamprosate, almitrine, amlexanox, azelastine, baclofen,carbetapentane, cinacalcet, dexbrompheniramine, diethylcarbamazine,D-mannose, fenspiride, fexofenadine, ifenprodil, mexiletine,nicergoline, tolperisone, torasemide, triamterene, piribedil,levosimendan, cimetidine, diprophylline, idebenone or rilmenidine, aswell as to the use of such composition in the treatment of diabetes or arelated disorder in a mammalian in need thereof.

A particular object of this invention relates to compositions comprising(i) triamterene and (ii) a compound selected from the group consistingof acamprosate, almitrine, amlexanox, azelastine, baclofen,carbetapentane, cinacalcet, dexbrompheniramine, diethylcarbamazine,D-mannose, fenspiride, fexofenadine, ifenprodil, mexiletine,nicergoline, tolperisone, torasemide, tolfenamic acid, piribedil,levosimendan, cimetidine, diprophylline, idebenone or rilmenidine, aswell as to the use of such composition in the treatment of diabetes or arelated disorder in a mammalian in need thereof.

Another particular object of this invention relates to compositionscomprising (i) piribedil, and (ii) a compound selected from the groupconsisting of acamprosate, almitrine, amlexanox, azelastine, baclofen,carbetapentane, cinacalcet, dexbrompheniramine, diethylcarbamazine,D-mannose, fenspiride, fexofenadine, ifenprodil, mexiletine,nicergoline, tolperisone, torasemide, triamterene, tolfenamic acid,levosimendan, cimetidine, diprophylline, idebenone or rilmenidine, aswell as to the use of such composition in the treatment of diabetes or arelated disorder in a mammalian in need thereof.

In a most preferred embodiment, the compositions of this inventioncomprise at least one of the following drug combinations, for combined,separate or sequential administration:

-   -   ifenprodil and acamprosate,    -   ifenprodil and baclofen,    -   baclofen and acamprosate,    -   mexiletine and cinacalcet,    -   mexiletine and torasemide,    -   sulfisoxazole and torasemide,    -   azelastine and nicergoline,    -   idebenone and nicergoline,    -   carbetapentane and nicergoline,    -   almitrine and nicergoline,    -   cimetidine and nicergoline,    -   diethylcarbamazine and nicergoline,    -   ifenprodil and nicergoline,    -   azelastine and idebenone,    -   acamprosate and nicergoline,    -   azelastine and carbetapentane,    -   azelastine and almitrine,    -   idebenone and carbetapentane,    -   idebenone and almitrine,    -   triamterene and nicergoline,    -   D-mannose and nicergoline,    -   idebenone and diethylcarbamazine,    -   ifenprodil and fenspiride,    -   ifenprodil and torasemide,    -   ifenprodil and triamterene,    -   ifenprodil and tolfenamic acid,    -   fenspiride and torasemide,    -   fenspiride and triamterene,    -   fenspiride and tolfenamic acid,    -   torasemide and triamterene,    -   torasemide and tolfenamic acid,    -   triamterene and tolfenamic acid, or    -   D-mannose and baclofen.

Another object of this invention resides in the use of a composition asdefined above for controlling blood or plasma glucose level in amammalian in need thereof.

A further object of this invention resides in the use of a compositionas defined above for the manufacture of a medicament for controllingblood or plasma glucose level in a mammalian in need thereof.

A further object of this invention resides in the use of a compositionas defined above for the manufacture of a medicament for treatingdiabetes or a related disorder.

As indicated previously, in a composition or combination therapy of thisinvention, the compounds or drugs may be formulated together orseparately, and administered together, separately or sequentially.

The invention is particularly adapted for correcting dysregulations ofglucose levels in human patients having diabetes, pre-diabetes (alsoreferred to as IGT or IFG), metabolic syndrome, obesity, or acardiovascular disease implying a predisposition to diabetes.

A further object of the invention is a method of treating diabetes or arelated disorder, the method comprising simultaneously, separately orsequentially administering to a subject in need thereof an effectiveamount of a drug or drug combination as defined above.

In a preferred embodiment, the invention relates to a method of treatingdiabetes or a related disorder in a subject in need thereof, comprisingadministering simultaneously, separately or sequentially to the subjectan effective amount of at least one of the following drug combinations:

-   -   ifenprodil and acamprosate,    -   ifenprodil and baclofen,    -   baclofen and acamprosate,    -   mexiletine and cinacalcet,    -   mexiletine and torasemide,    -   sulfisoxazole and torasemide,    -   azelastine and nicergoline,    -   idebenone and nicergoline,    -   carbetapentane and nicergoline,    -   almitrine and nicergoline,    -   cimetidine and nicergoline,    -   diethylcarbamazine and nicergoline,    -   ifenprodil and nicergoline,    -   azelastine and idebenone,    -   acamprosate and nicergoline,    -   azelastine and carbetapentane,    -   azelastine and almitrine,    -   idebenone and carbetapentane,    -   idebenone and almitrine,    -   triamterene and nicergoline,    -   D-mannose and nicergoline,    -   idebenone and diethylcarbamazine,    -   ifenprodil and fenspiride,    -   ifenprodil and torasemide,    -   ifenprodil and triamterene,    -   ifenprodil and tolfenamic acid,    -   fenspiride and torasemide,    -   fenspiride and triamterene,    -   fenspiride and tolfenamic acid,    -   torasemide and triamterene,    -   torasemide and tolfenamic acid,    -   triamterene and tolfenamic acid, or    -   D-mannose and baclofen.

In a particular embodiment, the methods of treating diabetes or arelated disorder further comprise a step of measuring glucose bloodlevel in a blood sample from the mammalian subject, either prior toand/or after administration of the drug(s).

In this regard, a further object of the invention is a method ofcontrolling blood glucose level, the method comprising the steps of:

1) measuring blood glucose level in a blood sample from a mammaliansubject, and

2) administering to said subject an effective amount of a composition asdisclosed above.

In the methods of the invention, the step of measuring glucose level maybe repeated during the course of the treatment, e.g., to assess ormonitor treatment efficacy and/or to adjust the treatment regimen.

The compositions of the invention typically comprise one or severalpharmaceutically acceptable carriers or excipients. Also, for use in thepresent invention, the drugs or compounds are usually mixed withpharmaceutically acceptable excipients or carriers.

In this regard, a further object of this invention is a method ofpreparing a pharmaceutical composition, the method comprising mixing theabove compounds in an appropriate excipient or carrier.

According to preferred embodiments of the invention, as indicated above,the compounds are used as such or in the form of a pharmaceuticallyacceptable salt, prodrug, metabolite, or sustained release formulationthereof.

Although very effective in vitro and in vivo, depending on the subjector specific condition, the above methods, compositions or combinationtherapies may further be used in conjunction, association or combinationwith additional drugs or treatments.

Other additional diabetes therapies used in conjunction with drug(s) ordrug(s) combination(s) according to the present invention may compriseone or more drug(s) that regulate blood glucose level, one or moredrug(s) used for the treatment of hyperlipidemia orhypercholesterolemia, and/or one or more drug(s) that could be used, orare currently being evaluated in the frame of clinical trials, fortreating diabetes or a related disorder. Preferably, said one or moredrug(s) is/are selected from acarbose, acetohexamide, alogliptin,berberine, bezafibrate, bromocriptine, buformin, carbutamide,chlorpropamide, chromium picolinate, ciprofibrate, clofibrate,colesevelam, dexfenfluramine, dutogliptin, exenatide, fenofibrate,gemfibrozil, gemigliptin, glibenclamide, glibornuride, glicetanile,gliclazide, glimepiride, glipizide, gliquidone, glisentide,glyclopyramide, imidapril, insulin, inulin, lipoic acid, linagliptin,liraglutide, mecobalamin, metformin, miglitol, mitiglinide, nateglinide,orlistat, phenformin, pioglitazone, pramlintide, repaglinide,rosiglitazone, saxagliptin, sitagliptin, tolazamide, tolbutamide,vildagliptin and voglibose.

Illustrative CAS numbers for each of these compounds are provided inTable 2 below (side effects mainly from Sweetman, S. (ed.), Martindale:The Complete Drug Reference, London: Pharmaceutical Press, electronicversion (2011) and Nathan et al. (2009) [9]):

TABLE 2 Drug Name CAS number Side Effects Analogs of amylin pramlintide196078-30-5 Gastrointestinal Weight loss Glucagon-like peptide 1receptor agonists exenatide 141758-74-9 Gastrointestinal liraglutide204656-20-2 Weight loss Alphaglucosidase inhibitors acarbose 56180-94-0Gastrointestinal miglitol 72432-03-2 voglibose 83480-29-9 Dipeptidylpeptidase 4 inhibitors alogliptin 850649-62-6 Upper respiratoryberberine 2086-83-1; 633-65-8; infections 633-66-9 dutogliptin852329-66-9 gemigliptin 911637-19-9 linagliptin 668270-12-0 saxagliptin361442-04-8 sitagliptin 654671-78-0 vildagliptin 274901-16-5 Glinidesmitiglinide 145375-43-5 Weight gain nateglinide 105816-04-4Cardiovascular repaglinide 135062-02-1 complications HypoglycemiaSulfonylureas acetohexamide 968-81-0 Weight gain carbutamide 339-43-5Cardiovascular chlorpropamide 94-20-2 complications glibenclamide10238-21-8 Hypoglycaemia glibornuride 26944-48-9 Loss of efficacyglipizide 29094-61-9 with long-term use glimepiride 93479-97-1gliclazide 21187-98-4 gliquidone 33342-05-1 glisentide 32797-92-5glyclopyramide 631-27-6 tolbutamide 64-77-7 tolazamide 1156-19-0Fibrates bezafibrate 41859-67-0 Gastrointestinal ciprofibrate 52214-84-3Myopathy clofibrate 637-07-0; 882-09-7; 39087-48-4; 14613-30-0fenofibrate 49562-28-9 (fenofibrate); 42017-89-0 (fenofibric acid);856676-23-8 gemfibrozil 25812-30-0 Thiazolidinediones rosiglitazone122320-73-4; 302543-62-0; Peripheral edema 155141-29-0; 397263-60-4Congestive heart pioglitazone 111025-46-8; 112529-15-4 failureBiguanides buformin 1190-53-0 Gastrointestinal metformin 657-24-9;1115-70-4 Lactic acidosis phenformin 834-28-6 Others bromocriptine22260-51-1 Gastrointestinal, hypotension, cardiovascular complicationschromium picolinate 14639-25-9 N/A colesevelam 182815-44-7Gastrointestinal Hyperchloremic acidosis Increase of plasma-triglycerideconcentrations dexfenfluramine 3239-44-9 Cardiovascular complicationsimidapril 89396-94-1 Hypotension Cardiovascular complications Renalimpairment Upper respiratory tract symptoms Pancreatitis inulin9005-80-5 N/A lipoic acid 62-46-4 N/A mecobalamin 13422-55-4 N/Aorlistat 96829-58-2 Gastrointestinal Risk of liver toxicity Insulininsulin 9004-10-8; 11070-73-8; Hypo- 12584-58-6; 11061-68-0;glycemiaWeight 8063-29-4; 9004-21-1; gain 68859-20-1; 8049-62-5;53027-39-7; 9004-17-5; 116094-23-6; 9004-12-0; 51798-72-2; 11091-62-6169148-63-4; 160337-95-1; 207748-29-6; 133107-64-9; 874442-57-6

In this regard, an object of this invention relates to compositionscomprising:

-   -   at least one compound selected from the group consisting of        acamprosate, almitrine, amlexanox, azelastine, baclofen,        carbetapentane, cinacalcet, dexbromopheniramine,        diethylcarbamazine, D-mannose, fenspiride, fexofenadine,        ifenprodil, mexiletine, nicergoline, tolperisone, torasemide,        triamterene, tolfenamic acid, piribedil, levosimendan,        cimetidine, diprophylline, idebenone and rilmenidine, and    -   at least one compound selected from the group consisting of        acarbose, acetohexamide, alogliptin, berberine, bezafibrate,        bromocriptine, buformin, carbutamide, chlorpropamide, chromium        picolinate, ciprofibrate, clofibrate, colesevelam,        dexfenfluramine, dutogliptin, exenatide, fenofibrate,        gemfibrozil, gemigliptin, glibenclamide, glibornuride,        glicetanile, gliclazide, glimepiride, glipizide, gliquidone,        glisentide, glyclopyramide, imidapril, insulin, inulin, lipoic        acid, linagliptin, liraglutide, mecobalamin, metformin,        miglitol, mitiglinide, nateglinide, orlistat, phenformin,        pioglitazone, pramlintide, repaglinide, rosiglitazone,        saxagliptin, sitagliptin, tolazamide, tolbutamide, vildagliptin        and voglibose,

as well as to the use of such compositions in the treatment of diabetesor a related disorder in a mammalian subject in need thereof.

Another preferred object of this invention relates to compositionscomprising (i) a compound selected from the group consisting ofacamprosate, almitrine, azelastine, baclofen, carbetapentane,cinacalcet, dexbrompheniramine, diethylcarbamazine, D-mannose,fenspiride, ifenprodil, levosimendan, mexiletine, nicergoline,tolfenamic acid, tolperisone, triamterene or torasemide, in combinationwith (ii) a compound selected from the group consisting of acarbose,acetohexamide, alogliptin, berberine, bezafibrate, bromocriptine,buformin, carbutamide, chlorpropamide, chromium picolinate,ciprofibrate, clofibrate, colesevelam, dexfenfluramine, dutogliptin,exenatide, fenofibrate, gemfibrozil, gemigliptin, glibenclamide,glibornuride, glicetanile, gliclazide, glimepiride, glipizide,gliquidone, glisentide, glyclopyramide, imidapril, insulin, inulin,lipoic acid, linagliptin, liraglutide, mecobalamin, metformin, miglitol,mitiglinide, nateglinide, orlistat, phenformin, pioglitazone,pramlintide, repaglinide, rosiglitazone, saxagliptin, sitagliptin,tolazamide, tolbutamide, vildagliptin and voglibose, as well as to theuse of such compositions in the treatment of diabetes or a relateddisorder in a mammalian subject in need thereof.

An even more preferred object of this invention relates to compositionscomprising a compound selected from the group consisting of acamprosate,almitrine, azelastine, baclofen, carbetapentane, cinacalcet,dexbrompheniramine, diethylcarbamazine, D-mannose, fenspiride,ifenprodil, levosimendan, mexiletine, nicergoline, tolfenamic acid,tolperisone, torasemide or triamterene, in combination with one compoundselected from the group consisting of glibenclamide, repaglinide,metformin and pioglitazone, as well as to the use of such compositionsin the treatment of diabetes or a related disorder in a mammaliansubject in need thereof.

A very preferred object of this invention relates to compositionscomprising a compound selected from the group consisting of acamprosate,almitrine, azelastine, baclofen, carbetapentane, cinacalcet,dexbrompheniramine, diethylcarbamazine, D-mannose, fenspiride,ifenprodil, levosimendan, mexiletine, nicergoline, tolfenamic acid,tolperisone, torasemide and triamterene, in combination with metformin,as well as to the use of such compositions in the treatment of diabetesor a related disorder in a mammalian subject in need thereof.

A more preferred object of this invention relates to compositionscomprising (i) at least two compounds selected from the group consistingof acamprosate, almitrine, amlexanox, azelastine, baclofen,carbetapentane, cinacalcet, dexbromopheniramine, diethylcarbamazine,D-mannose, fenspiride, fexofenadine, ifenprodil, mexiletine,nicergoline, tolperisone, torasemide, triamterene, tolfenamic acid,piribedil, levosimendan, cimetidine, diprophylline, idebenone andrilmenidine, and (ii) a compound selected from the group consisting ofacarbose, acetohexamide, alogliptin, berberine, bezafibrate,bromocriptine, buformin, carbutamide, chlorpropamide, chromiumpicolinate, ciprofibrate, clofibrate, colesevelam, dexfenfluramine,dutogliptin, exenatide, fenofibrate, gemfibrozil, gemigliptin,glibenclamide, glibornuride, glicetanile, gliclazide, glimepiride,glipizide, gliquidone, glisentide, glyclopyramide, imidapril, insulin,inulin, lipoic acid, linagliptin, liraglutide, mecobalamin, metformin,miglitol, mitiglinide, nateglinide, orlistat, phenformin, pioglitazone,pramlintide, repaglinide, rosiglitazone, saxagliptin, sitagliptin,tolazamide, tolbutamide, vildagliptin and voglibose, as well as to theuse of such compositions in the treatment of diabetes or a relateddisorder in a mammalian subject in need thereof.

A more preferred object of this invention relates to compositionscomprising:

-   -   at least two compounds selected from the group consisting of        acamprosate, almitrine, azelastine, baclofen, carbetapentane,        cinacalcet, dexbrompheniramine, diethylcarbamazine, D-mannose,        fenspiride, ifenprodil, levosimendan, mexiletine, nicergoline,        tolfenamic acid, tolperisone, torasemide and triamterene,    -   in combination with a compound selected from the group        consisting of acarbose, acetohexamide, alogliptin, berberine,        bezafibrate, bromocriptine, buformin, carbutamide,        chlorpropamide, chromium picolinate, ciprofibrate, clofibrate,        colesevelam, dexfenfluramine, dutogliptin, exenatide,        fenofibrate, gemfibrozil, gemigliptin, glibenclamide,        glibornuride, glicetanile, gliclazide, glimepiride, glipizide,        gliquidone, glisentide, glyclopyramide, imidapril, insulin,        inulin, lipoic acid, linagliptin, liraglutide, mecobalamin,        metformin, miglitol, mitiglinide, nateglinide, orlistat,        phenformin, pioglitazone, pramlintide, repaglinide,        rosiglitazone, saxagliptin, sitagliptin, tolazamide,        tolbutamide, vildagliptin and voglibose,

as well as to the use of such compositions in the treatment of diabetesor a related disorder in a mammalian subject in need thereof.

An even more preferred object of this invention relates to compositionscomprising at least two compounds selected from the group consisting ofacamprosate, almitrine, azelastine, baclofen, carbetapentane,cinacalcet, dexbrompheniramine, diethylcarbamazine, D-mannose,fenspiride, ifenprodil, levosimendan, mexiletine, nicergoline,tolfenamic acid, tolperisone, torasemide and triamterene, in combinationwith one compound selected from the group consisting of glibenclamide,repaglinide, metformin and pioglitazone, as well as to the use of suchcompositions in the treatment of diabetes or a related disorder in amammalian subject in need thereof.

Another preferred object of this invention relates to compositionscomprising at least two compounds selected from the group consisting ofacamprosate, almitrine, azelastine, baclofen, carbetapentane,cinacalcet, dexbrompheniramine, diethylcarbamazine, D-mannose,fenspiride, ifenprodil, levosimendan, mexiletine, nicergoline,tolfenamic acid, tolperisone, torasemide and triamterene, in combinationwith one compound selected from the group consisting of bezafibrate,ciprofibrate, clofibrate, gemfibrozil, fenofibrate and orlistat, as wellas to the use of such compositions in the treatment of diabetes or arelated disorder in a mammalian subject in need thereof.

Another preferred object of this invention relates to compositionscomprising baclofen and acamprosate, in combination with one compoundselected from the group consisting of pioglitazone, rosiglitazone,bezafibrate, ciprofibrate, clofibrate, fenofibrate, gemfibrozil,buformin, colesevelam and orlistat, as well as to the use of suchcompositions in the treatment of diabetes or a related disorder in amammalian subject in need thereof.

A more preferred object of this invention relates to compositionscomprising metformin in combination with at least one of the followingcombinations of compounds:

-   -   ifenprodil and acamprosate,    -   ifenprodil and baclofen,    -   baclofen and acamprosate,    -   mexiletine and cinacalcet,    -   mexiletine and torasemide,    -   sulfisoxazole and torasemide,    -   azelastine and nicergoline,    -   idebenone and nicergoline,    -   carbetapentane and nicergoline,    -   almitrine and nicergoline,    -   cimetidine and nicergoline,    -   diethylcarbamazine and nicergoline,    -   ifenprodil and nicergoline,    -   azelastine and idebenone,    -   acamprosate and nicergoline,    -   azelastine and carbetapentane,    -   azelastine and almitrine,    -   idebenone and carbetapentane,    -   idebenone and almitrine,    -   triamterene and nicergoline,    -   D-mannose and nicergoline,    -   idebenone and diethylcarbamazine,    -   ifenprodil and fenspiride,    -   ifenprodil and torasemide,    -   ifenprodil and triamterene,    -   ifenprodil and tolfenamic acid,    -   fenspiride and torasemide,    -   fenspiride and triamterene,    -   fenspiride and tolfenamic acid,    -   torasemide and triamterene,    -   torasemide and tolfenamic acid,    -   triamterene and tolfenamic acid, or    -   D-mannose and baclofen.

Another more preferred object of this invention relates to the use ofsuch compositions in the treatment of diabetes or a related disorder ina mammalian subject in need thereof. The above combinations comprisingone or more drugs of the invention and a known drug listed in Table 2,or a combination thereof, allow a diminution of the dosage of thesedrugs for the treatment of diabetes. This lowering permits the avoidanceor delays the appearance of known drawbacks for these drugs (Table 2;e.g., resistance to treatment increasing with time, weight gain,peripheral edema, renal toxicity due to lactic acidosis).

As already mentioned, in the above-mentioned combinatorial therapies,drugs may be administered together or separately, at the same time orsequentially, depending on the specific pharmacokinetic features of eachdrug, in order to produce a combined or synergistic effect in theorganism.

The above combinations can also be used in conjunction with any othertherapy used for regulating glucose blood level; such therapy can be,more particularly, the well-known diabetes-specific diet (high indietary fiber, low in fat, low in sugar), natural supplement such asextracts or parts of Cinnamonum cassia, moringa, ginseng, gymnema, aloevera, walnut leaf, myrcia, garlic, Grifola frondosa, Reishi, Agaricusblazei, Agrocibe cylindracea, Cordyceps, agrimony, alfalfa, coriander,eucalyptus, or juniper, as well as oligo elements like chromium,vanadium, magnesium, or zinc.

Therapy according to the invention may be provided at home, a doctor'soffice, a clinic, a hospital's outpatient department, or a hospital, sothat one can observe the therapy's effects closely and make anyadjustments that are needed as a function of measured blood glucoselevels.

The duration of the therapy depends on the stage of the disease beingtreated, age and condition of the patient, and how the patient respondsto the treatment. The dosage, frequency and mode of administration ofthe drugs or each component of the drug combinations of the inventioncan be controlled independently. For example, one drug of a combinationmay be administered orally while the second drug may be administeredintramuscularly or at different times throughout the day. The drugs mayalso be formulated together such that one administration delivers alldrugs.

The treatment of the invention can be administered during particularperiods of the day, for example, on time or just before or just afterthe time the glucose concentration reaches its peak in the plasma.Glycemia can easily be determined, even by the patients themselves,using different commercially available glucometers. The time and dosageof the treatment can therefore be adapted as a function of the measuredglycemia. If there is sequential administration, the administration canbe dependent on the blood glucose concentration, for example, the firstactive ingredient is administered before the glucose peak while theother is administered after the glucose peak. Usually, the glucoseconcentration reaches its peak in the plasma of a subject after meals.

The administration of each drug of the combination may be by anysuitable means that results in a concentration of the drug that,combined with the other component, is able to control blood glucoselevels.

While it is possible for the drug or the drugs of the combination to beadministered as the pure chemical it is preferable to present them as apharmaceutical composition, also referred to in this context as apharmaceutical formulation. Possible compositions include those suitablefor oral, rectal, topical (including transdermal, buccal andsublingual), or parenteral (including subcutaneous, intramuscular,intravenous and intradermal) administration.

More commonly these pharmaceutical formulations are prescribed to thepatient in “patient packs” containing a number dosing units or othermeans for administration of metered unit doses for use during a distincttreatment period in a single package, usually a blister pack. Patientpacks have an advantage over traditional prescriptions, where apharmacist divides a patient's supply of a pharmaceutical from a bulksupply, in that the patient always has access to the package insertcontained in the patient pack, normally missing in traditionalprescriptions. The inclusion of a package insert has been shown toimprove patient compliance with the physician's instructions. Thus, theinvention further includes a pharmaceutical formulation, as hereinbefore described, in combination with packaging material suitable forsaid formulation. In such a patient pack the intended use of aformulation for the combination treatment can be inferred byinstructions, facilities, provisions, adaptations and/or other means tohelp use the formulation most suitably for the treatment. Such measuresmake a patient pack specifically suitable and adapted for use fortreatment with the compositions of the present invention.

The drug may be contained, in any appropriate amount, in any suitablecarrier substance. The drug may be present in an amount of up to 99% byweight of the total weight of the composition. The composition may beprovided in a dosage form that is suitable for the oral, parenteral(e.g., intravenous, intramuscular), rectal, cutaneous, nasal, vaginal,inhalant, skin (patch), or ocular administration route. Thus, thecomposition may be in the form of, e.g., tablets, capsules, pills,powders, granulates, suspensions, emulsions, solutions, gels includinghydrogels, pastes, ointments, creams, plasters, drenches, osmoticdelivery devices, suppositories, enemas, injectables, implants, sprays,or aerosols.

The pharmaceutical compositions may be formulated according toconventional pharmaceutical practice (see, e.g., Remington: The Scienceand Practice of Pharmacy (20th ed.), ed. A. R. Gennaro, LippincottWilliams & Wilkins, 2000 and Encyclopedia of Pharmaceutical Technology,eds. J. Swarbrick and J. C. Boylan, 1988-1999, Marcel Dekker, New York).

Pharmaceutical compositions according to the invention may be formulatedto release the active drug substantially immediately upon administrationor at any predetermined time or time period after administration.

Controlled release formulations include (i) formulations that create asubstantially constant concentration of the drug(s) within the body overan extended period of time; (ii) formulations that after a predeterminedlag time create a substantially constant concentration of the drug(s)within the body over an extended period of time; (iii) formulations thatsustain drug(s) action during a predetermined time period by maintaininga relatively constant, effective drug level in the body with concomitantminimization of undesirable side effects associated with fluctuations inthe plasma level of the active drug substance; (iv) formulations thatlocalize drug(s) action by, e.g., spatial placement of a controlledrelease composition adjacent to or in the diseased tissue or organ; and(v) formulations that target drug(s) action by using carriers orchemical derivatives to deliver the drug to a particular target celltype.

Administration of drugs in the form of a controlled release formulationis especially preferred in cases in which the drug has (i) a narrowtherapeutic index (i.e., the difference between the plasma concentrationleading to harmful side effects or toxic reactions and the plasmaconcentration leading to a therapeutic effect is small (in general, thetherapeutic index, TI, is defined as the ratio of median lethal dose(LD50) to median effective dose (ED50)); (ii) a narrow absorption windowin the gastro-intestinal tract; or (iii) a very short biologicalhalf-life so that frequent dosing during a day is required in order tosustain the plasma level at a therapeutic level.

Any of a number of strategies can be pursued in order to obtaincontrolled release in which the rate of release outweighs the rate ofmetabolism of the drug in question. Controlled release may be obtainedby appropriate selection of various formulation parameters andingredients, including, e.g., various types of controlled releasecompositions and coatings. Thus, the drug is formulated with appropriateexcipients into a pharmaceutical composition that, upon administration,releases the drug in a controlled manner (single or multiple unit tabletor capsule compositions, oil solutions, suspensions, emulsions,microcapsules, microspheres, nanoparticles, patches, and liposomes).

Solid Dosage Forms for Oral Use

Formulations for oral use include tablets containing the composition ofthe invention in a mixture with non-toxic pharmaceutically acceptableexcipients. These excipients may be, for example, inert diluents orfillers (e.g., sucrose, microcrystalline cellulose, starches includingpotato starch, calcium carbonate, sodium chloride, calcium phosphate,calcium sulfate, or sodium phosphate); granulating and disintegratingagents (e.g., cellulose derivatives including microcrystallinecellulose, starches including potato starch, croscarmellose sodium,alginates, or alginic acid); binding agents (e.g., acacia, alginic acid,sodium alginate, gelatin, starch, pregelatinized starch,microcrystalline cellulose, carboxymethylcellulose sodium,methylcellulose, hydroxypropyl methylcellulose, ethylcellulose,polyvinylpyrrolidone, or polyethylene glycol); and lubricating agents,glidants, and antiadhesives (e.g., stearic acid, silicas, or talc).Other pharmaceutically acceptable excipients can be colorants, flavoringagents, plasticizers, humectants, buffering agents, and the like.

The tablets may be uncoated or they may be coated by known techniques,optionally to delay disintegration and absorption in thegastrointestinal tract and thereby providing a sustained action over alonger period. The coating may be adapted to release the active drugsubstance in a predetermined pattern (e.g., in order to achieve acontrolled release formulation) or it may be adapted not to release theactive drug substance until after passage of the stomach (entericcoating). The coating may be a sugar coating, a film coating (e.g.,based on hydroxypropyl methylcellulose, methylcellulose, methylhydroxyethylcellulose, hydroxypropylcellulose, carboxymethylcellulose,acrylate copolymers, polyethylene glycol and/or polyvinylpyrrolidone),or an enteric coating (e.g., based on methacrylic acid copolymer,cellulose acetate phthalate, hydroxypropyl methylcellulose phthalate,hydroxypropyl methylcellulose acetate succinate, polyvinyl acetatephthalate, shellac, and/or ethylcellulose). A time delay material suchas glyceryl monostearate or glyceryl distearate may be employed.

The solid tablet compositions may include a coating adapted to protectthe composition from unwanted chemical changes (e.g., chemicaldegradation prior to the release of the active drug substance). Thecoating may be applied on the solid dosage form in a similar manner tothat described in the Encyclopedia of Pharmaceutical Technology.

Drugs may be mixed together in the tablet, or may be partitioned. Forexample, a first drug is contained on the inside of the tablet, and asecond drug is on the outside, such that a substantial portion of thesecond drug is released prior to the release of the first drug.

Formulations for oral use may also be presented as chewable tablets, oras hard gelatin capsules wherein the active ingredient is mixed with aninert solid diluent (e.g., potato starch, microcrystalline cellulose,calcium carbonate, calcium phosphate or kaolin), or as soft gelatincapsules wherein the active ingredient is mixed with water or an oilmedium, for example, liquid paraffin or olive oil. Powders andgranulates may be prepared using the ingredients mentioned above undertablets and capsules in a conventional manner.

Controlled release compositions for oral use may, e.g., be constructedto release the active drug by controlling the dissolution and/or thediffusion of the active drug substance.

Dissolution or diffusion-controlled release can be achieved byappropriate coating of a tablet, capsule, pellet, or granulatedformulation of drugs, or by incorporating the drug into an appropriatematrix. A controlled release coating may include one or more of thecoating substances mentioned above and/or, e.g., shellac, beeswax,glycowax, castor wax, carnauba wax, stearyl alcohol, glycerylmonostearate, glyceryl distearate, glycerol palmitostearate,ethylcellulose, acrylic resins, DL-polylactic acid, cellulose acetatebutyrate, polyvinyl chloride, polyvinyl acetate, vinyl pyrrolidone,polyethylene, polymethacrylate, methyl methacrylate,2-hydroxymethacrylate, methacrylate hydrogels, 1,3 butylene glycol,ethylene glycol methacrylate, and/or polyethylene glycols. In acontrolled release matrix formulation, the matrix material may alsoinclude, e.g., hydrated methylcellulose, carnauba wax, stearyl alcohol,carbopol 934, silicone, glyceryl tristearate, methyl acrylate-methylmethacrylate, polyvinyl chloride, polyethylene, and/or halogenatedfluorocarbon.

A controlled release composition containing one or more of the drugs ofthe claimed combinations may also be in the form of a buoyant tablet orcapsule (i.e., a tablet or capsule that, upon oral administration,floats on top of the gastric contents for a certain period of time). Abuoyant tablet formulation of the drug(s) can be prepared by granulatinga mixture of the drug(s) with excipients and 20-75% w/w ofhydrocolloids, such as hydroxyethylcellulose, hydroxypropylcellulose, orhydroxypropylmethylcellulose. The obtained granules can then becompressed into tablets. On contact with the gastric juice, the tabletforms a substantially water-impermeable gel barrier around its surface.This gel barrier takes part in maintaining a density of less than one,thereby allowing the tablet to remain buoyant in the gastric juice.

Liquids for Oral Administration

Powders, dispersible powders, or granules suitable for preparation of anaqueous suspension by addition of water are convenient dosage forms fororal administration. Formulation as a suspension provides the activeingredient in a mixture with a dispersing or wetting agent, suspendingagent, and one or more preservatives. Suitable suspending agents are,for example, sodium carboxymethylcellulose, methylcellulose, sodiumalginate, and the like.

Parenteral Compositions

The pharmaceutical composition may also be administered parenterally byinjection, infusion or implantation (intravenous, intramuscular,subcutaneous, or the like) in dosage forms, formulations, or viasuitable delivery devices or implants containing conventional, non-toxicpharmaceutically acceptable carriers and adjuvants. The formulation andpreparation of such compositions are well-known to those skilled in theart of pharmaceutical formulation.

Compositions for parenteral use may be provided in unit dosage forms(e.g., in single-dose ampoules), or in vials containing several dosesand in which a suitable preservative may be added (see below). Thecomposition may be in form of a solution, a suspension, an emulsion, aninfusion device, or a delivery device for implantation or it may bepresented as a dry powder to be reconstituted with water or anothersuitable vehicle before use. Apart from the active drug(s), thecomposition may include suitable parenterally acceptable carriers and/orexcipients. The active drug(s) may be incorporated into microspheres,microcapsules, nanoparticles, liposomes, or the like for controlledrelease. The composition may include suspending, solubilizing,stabilizing, pH-adjusting, and/or dispersing agents.

The pharmaceutical compositions according to the invention may be in aform suitable for sterile injection. To prepare such a composition, thesuitable active drug(s) are dissolved or suspended in a parenterallyacceptable liquid vehicle. Among acceptable vehicles and solvents thatmay be employed are water, water adjusted to a suitable pH by additionof an appropriate amount of hydrochloric acid, sodium hydroxide or asuitable buffer, 1,3-butanediol, Ringer's solution, and isotonic sodiumchloride solution. The aqueous formulation may also contain one or morepreservatives (e.g., methyl, ethyl or n-propyl p-hydroxybenzoate). Incases where one of the drugs is only sparingly or slightly soluble inwater, a dissolution-enhancing or solubilizing agent can be added, orthe solvent may include 10-60% w/w of propylene glycol or the like.

Controlled release parenteral compositions may be in form of aqueoussuspensions, microspheres, microcapsules, magnetic microspheres, oilsolutions, oil suspensions, or emulsions. Alternatively, the activedrug(s) may be incorporated in biocompatible carriers, liposomes,nanoparticles, implants, or infusion devices. Materials for use in thepreparation of microspheres and/or microcapsules are, e.g.,biodegradable/bioerodible polymers such as polygalactin, poly-(isobutylcyanoacrylate), or poly-(2-hydroxyethyl-L-glutamine). Biocompatiblecarriers that may be used when formulating a controlled releaseparenteral formulation are carbohydrates (e.g., dextrans), proteins(e.g., albumin), lipoproteins, or antibodies. Materials for use inimplants can be non-biodegradable (e.g., polydimethyl siloxane) orbiodegradable (e.g., poly(caprolactone), poly(glycolic acid) orpoly(ortho esters)).

Alternative Routes

Although less preferred and less convenient, other administrationroutes, and therefore other formulations, may be contemplated. In thisregard, for rectal application, suitable dosage forms for a compositioninclude suppositories (emulsion or suspension type) and rectal gelatincapsules (solutions or suspensions). In a typical suppositoryformulation, the active drug(s) are combined with an appropriatepharmaceutically acceptable suppository base such as cocoa butter,esterified fatty acids, glycerinated gelatin, and various water-solubleor dispersible bases like polyethylene glycols. Various additives,enhancers, or surfactants may be incorporated.

The pharmaceutical compositions may also be administered topically onthe skin for percutaneous absorption in dosage forms or formulationscontaining conventionally non-toxic pharmaceutical acceptable carriersand excipients including microspheres and liposomes. The formulationsinclude creams, ointments, lotions, liniments, gels, hydrogels,solutions, suspensions, sticks, sprays, pastes, plasters, and otherkinds of transdermal drug delivery systems. The pharmaceuticallyacceptable carriers or excipients may include emulsifying agents,antioxidants, buffering agents, preservatives, humectants, penetrationenhancers, chelating agents, gel-forming agents, ointment bases,perfumes, and skin protective agents.

The preservatives, humectants, and penetration enhancers may beparabens, such as methyl or propyl p-hydroxybenzoate, and benzalkoniumchloride, glycerin, propylene glycol, urea, etc.

The pharmaceutical compositions described above for topicaladministration on the skin may also be used in connection with topicaladministration onto or close to the part of the body that is to betreated. The compositions may be adapted for direct application orapplication by means of special drug delivery devices such as dressingsor, alternatively, plasters, pads, sponges, strips, or other forms ofsuitable flexible material.

Dosages and Duration of the Treatment

A composition according to the invention is administered to a subjectorally or by subcutaneous, intravenous or intramuscular injections, atdifferent times of day, to alter the blood glucose level. In carryingout this process, where it is desired to modify, regulate, or normalizethe blood glucose level of a mammalian, to treat diabetes or a relateddisorder, or both, a composition of the invention is administered in adosage amount sufficient to alter, regulate or normalize the glucoselevel in the blood of the subject. A composition of the invention can beadministered to a mammalian, particularly a human, exhibiting anabnormal blood glucose level, at a particular period of the day, forexample, on time or just before or just after the time the glucoseconcentration reaches its peak in the plasma. The level of glucose inthe blood of a mammal is time-of-day dependent and cyclic. The glucoselevel in blood rises and falls at different times of day, preferablydependent on the time of meals and physical activity/exercise. Usually,the glucose concentration reaches its peak in the plasma of a subjectafter meals; therefore a composition of the invention can be, forexample, preferably administered from 2 hours before meals to 2 hoursafter meals, more preferably from one hour before meals to one hourafter meals, and even more preferably during meals, to achieve maximaltherapeutic efficacy.

It will be appreciated that the drugs of the combination may beadministered concomitantly, either in the same or differentpharmaceutical formulations or sequentially. A minimum requirement for acombination according to this description is that the combination shouldbe intended for combined use with the benefit of the efficacious effectof the combination of the active ingredients. The intended use of acombination can be inferred by facilities, provisions, adaptationsand/or other means to help use the combination according to theinvention.

Therapeutically effective amounts of the drugs in a combination of thisinvention include, e.g., amounts that are effective for controllingblood or plasma glucose levels.

Administration can be one to several times daily for several days toseveral years, and may even be for the life of the patient. Chronic orat least periodically repeated long-term administration is indicated inmost cases.

The term “unit dosage form” refers to physically discrete units (such ascapsules, tablets, or loaded syringe cylinders) suitable as unitarydosages for human subjects, each unit containing a predeterminedquantity of active material or materials calculated to produce thedesired therapeutic effect, in association with the requiredpharmaceutical carrier.

The amount of each drug in a preferred unit dosage composition dependsupon several factors including the administration method, the bodyweight and age of the patient, the stage of the disease, and the risk ofpotential side effects considering the general health status of theperson to be treated. Additionally, pharmacogenomic (the effect ofgenotype on the pharmacokinetic, pharmacodynamic or efficacy profile ofa therapeutic) information about a particular patient may affect thedosage used.

Except when responding to especially impaired glucose levels wherehigher dosages may be required, the preferred dosage of each drug in thecombination will usually lie within the range of doses not above thedosage usually prescribed for long-term maintenance treatment or provento be safe in phase 3 clinical studies.

One remarkable advantage of the invention is that each compound may beused at low doses in a combination therapy, while producing, incombination, a substantial clinical benefit to the patient. Thecombination therapy may indeed be effective at doses where the compoundshave individually low or no effect. Accordingly, a particular advantageof the invention lies in the ability to use sub-optimal doses of eachcompound, i.e., doses which are lower than the therapeutic doses usuallyprescribed, preferably ½ of therapeutic doses, more preferably ⅓, ¼, ⅕,or even more preferably 1/10 of therapeutic doses. In particularexamples, doses as low as 1/20, 1/30, 1/50, 1/100, or even lower, oftherapeutic doses are used.

At such sub-therapeutic dosages, the compounds would exhibit no or fewerside effects, while the combinations according to the invention arefully effective in controlling glucose blood or plasma levels.

A preferred dosage corresponds to amounts from 1% to 50% of thoseusually prescribed for long-term maintenance treatment.

The most preferred dosage may correspond to amounts from 1% to 10% ofthose usually prescribed for long-term maintenance treatment.

Specific examples of dosages of drugs for use in the invention areprovided below:

-   -   Acamprosate orally from about 9 to 200 mg per day,    -   Almitrine orally from about 0.5 to 10 mg per day,    -   Amlexanox orally from about 0.75 to 15 mg per day,    -   Azelastine orally from about 0.04 to 0.4 mg per day,    -   Baclofen orally from about 0.15 to 50 mg per day,    -   Carbetapentane orally from about 0.6 to 18 mg per day,    -   Cimetidine orally from about 4 to 160 mg per day,    -   Cinacalcet orally from about 0.3 to 36 mg per day,    -   D-mannose orally from 0.01 to 1.6 g per day,    -   Dexbrompheniramine orally from about 0.06 to 1.2 mg per day,    -   Diethylcarbamazine orally from about 0.6 to 600 mg per day,    -   Diprophylline orally from about 9 to 320 mg per day,    -   Fenspiride orally from 1.6 to 24 mg per day,    -   Fexofenadine orally from 1.2 to 18 mg per day,    -   Idebenone orally from about 4.5 mg to 225 mg per day,    -   Ifenprodil orally from about 0.4 to 6 mg per day,    -   Levosimendan orally from about 0.05 to 4 mg per day,    -   Metformin orally from about 1 mg to 2.5 mg per day,    -   Mexiletine orally from about 6 to 120 mg per day,    -   Nicergoline orally from about 0.6 to 6 mg per day,    -   Piribedil orally from about 0.8 to 25 mg per day,    -   Rilmenidine orally from about 10 to 200 μg per day,    -   Tolperisone orally from about 1.5 to 4.5 mg per day,    -   Tolfenamic acid orally from about 3 to 60 mg per day,    -   Torasemide orally from about 0.05 to 4 mg per day, and    -   Triamterene orally from about 1.5 to 25 mg per day.

In combinations of the invention, the molar ratio between drugs mayvary, e.g., from 0.001 to 1000. Also, the ratio of the drug(s) andexcipient in a composition of the invention advantageously vary between0.001 and 1000.

It will be understood that the amount of the drug actually administeredwill be determined by a physician, in light of the relevantcircumstances including the condition or conditions to be treated, theexact composition to be administered, the age, weight, and response ofthe individual patient, the severity of the patient's symptoms, and thechosen route of administration. Therefore, the above dosage ranges areintended to provide general guidance and support for the teachingsherein, but are not intended to limit the scope of the invention.

The following examples are given for purposes of illustration and not byway of limitation.

EXAMPLES

Diabetes is a metabolic disease that profoundly affects energyhomeostasis and the high plasmatic level of glucose observed in patientscan have multiple causes. Type 1 diabetes is characterized by thedestruction of β cells of Langerhans islets. Type 2 diabetes ischaracterized, in part, by a decrease of the production of insulin bythe pancreatic β cells, a progressive death of β cells, insulinresistance (i.e., lower capture of glucose by muscle cells andadipocytes), or an abnormal elevation of hepatic gluconeogenesis. Hence,the efficacy determination of candidate compounds is based on several invitro and in vivo studies in order to address most of the metabolic andphysiological impairments characterizing this complex pathology. Thedrugs were first tested individually, followed by assays of theircombinatorial action. Drug activity is determined on various modelswhich illustrate different physiological features representative of anabnormal blood glucose level such as those involved in diabetes orrelated disorders.

1. In Vitro Studies

1.1 Prevention of Beta Cells Apoptosis

Drugs of the invention have been tested for their efficiency inprotecting beta cells from apoptosis. Such activity could be consideredof use in type 1 diabetes as well as type 2 diabetes.

Cell Culture and Media

The beta pancreatic INS-1 cells have been selected for this study. Thecells are cultured in complete medium, RPMI 1640 10 mM glucosesupplemented with 1 mM sodium pyruvate, 50 μM 2-mercaptoethanol, 2 mMglutamine, 10 mM HEPES, 100 IU/mL penicillin, 100 μg/mL streptomycin and10% heat-inactivated fetal calf serum (FCS), as described by Asfari etal. (23). INS-1 cells are plated (4.5×10⁴ cells/well) in 96-wellpoly-ornithine coated plates and cultured at 37° C. in a humidifiedatmosphere of 95% air/5% CO₂. The day after, cells are pre-incubatedwith the tested molecules for 1 h. Then, after a medium change, cellsare cultured for 24 h in a medium containing the tested molecules and 30mM glucose, 0.05 mM myristic acid, 25 ng/mL INF, 25 ng/mL TNF and 5ng/mL IL.

Apoptosis Quantification

The efficacy of compounds to prevent apoptosis is then evaluated by thehighly specific apoptosis detection kit from Chemicon (Ref. APT225).This procedure is based on the detection of single-stranded DNA (ssDNA)which is a specific marker of apoptotic cells (24).

Results are expressed in optical density (OD) arbitrary unit and % ofreduction of the apoptosis induced by apoptotic condition. Following aDunnett t-test, all compounds showing a significant decrease in % ofapoptotic cells compared to apoptotic control conditions are consideredactive.

Results

Results are shown in FIG. 1 and Table 3 and demonstrate that the drugsof the invention, when tested alone, induce a substantial protectiveeffect against apoptosis of beta cells. In FIG. 1, D-mannose induces asignificant and complete protection of beta cells against apoptosis whencompared to non-treated cells in apoptotic conditions. D-mannose confersmore than 129% of protection against apoptosis. Similarly, Table 3displays the percentage of protection conferred by drugs of theinvention.

TABLE 3 Drugs Percentage of apoptosis reduction D-mannose 129% Mexiletine 74% Tolperisone 78% Baclofen 84% Cinacalcet 167% Dexbrompheniramine 76% Diethylcarbamazine 44% Nicergoline 112% Torasemide 67% Triamterene 64% Almitrine 103%  Azelastine 81%Acamprosate 49% Carbetapentane 103%  Ifenprodil 54% Levosimendan 118% 

1.2 Insulin Secretion in Response to Glucose Stimulation

Cell Culture and Media

The beta pancreatic INS-1 cells have been selected for their insulinsecretion profile in response to glucose and to other physiological orpharmacological insulin secretagogues such as sulfonylureas and GLP-1.The cells are cultured in complete medium, RPMI 1640 10 mM glucosesupplemented with 1 mM sodium pyruvate, 50 μM 2-mercaptoethanol, 2 mMglutamine, 10 mM HEPES, 100 IU/mL penicillin, 100 μg/mL streptomycin and10% heat-inactivated fetal calf serum (FCS), as described by Asfari etal. (23). For the insulin secretion assay, INS-1 cells are plated(4.5×10⁴ cells/well) and cultured in 96-well poly-ornithine coatedplates. After 3 days of culture at 37° C. in a humidified atmosphere of95% air/5% CO₂, the medium is removed and cells are cultured for 16 h ina medium containing 5 mM glucose, 1% FCS (and the tested drugs forlong-term evaluation).

The day of the insulin secretion test, the cells are washed withKrebs-Ringer Bicarbonate HEPES buffer (KRBH; pH 7.4) and 0.1% BovinSerum Albumin (BSA) and pre-incubated for 30 min at 37° C. in KRBH 0.1%BSA containing 2.8 mM glucose.

The cells are washed again with KRBH and incubated for 1 h in KRBH 0.1%BSA containing 3.5 mM glucose and the tested molecules. The supernatantsare collected for insulin determination and lactate dehydrogenase (LDH)activity measurement.

Insulin Quantification

The insulin concentration in the collected supernatants is measured byan ELISA kit according to the manufacturer's recommendations and using arat insulin antibody (Rat High Range Insulin ELISA, ALPCO Cat. no.80-INSRTH-E10). Very briefly, rat monoclonal antibodies specific forinsulin are immobilized to 96-well plates. Standards, samples andcontrols are added to the appropriate wells with a horseradishperoxidase enzyme-labeled monoclonal antibody (conjugate). Afterincubation, the microplates are washed to remove unbound conjugate and aTMB substrate solution is added to react with the bound conjugate.Finally, after addition of a stop solution, the optical density ismeasured at 450 nm using a reference wavelength of 620 nm. The intensityof the yellow color is directly proportional to the amount of insulinwithin the samples.

The efficacy of the drugs is demonstrated by evaluating the quantity ofinsulin (expressed in pmol/L) secreted in the absence or presence ofdrugs of the invention in the medium.

Results

Drugs of the invention induce insulin secretion in response to glucosestimulation. For example, FIGS. 2 and 3 show that triamterene (10 μM,+37%) and cinacalcet (1 μM, +55%), respectively, can significantlyenhance the secretion of insulin in response to glucose stimulation,following a short-term or long-term incubation, respectively.

1.3 Glucose Uptake in Muscles or Adipocytes

1.3.1 Glucose Uptake in Mouse Muscle Cells

Drugs of the invention have been tested in several models for insulinresistance. Glucose uptake-enhancing capacities of compositions of theinvention were measured both in muscle cells and in adipocytes either innormal or pathological conditions. Depending on culture conditions, themuscle cells either exhibit continuous mitosis or alternativelyterminally differentiate into myotubes.

Cell Culture and Media

H-2 Kb mouse muscle cells are grown for 4 days on 24-well plates coatedwith matrigel at a density of 0.8×10⁴ cells/well under permissiveconditions (33° C. in a humidified atmosphere of 95% air/10% CO₂; DMEM5.5 mM D-glucose supplemented with 20% FCS, 10% horse serum, 2%glutamine, 0.5% chicken embryo, 20 mU/mL mouse INFy , 100 U/mLpenicillin, and 100 μg/mL streptomycin) as described previously by Fryeret al. (25). For differentiation in myoblast, cells are switched tonon-permissive culture conditions (37° C. in a humidified atmosphere of95% air/5% CO₂; DMEM 5.5 mM D-glucose supplemented with 2% FCS, 10%horse serum, 2% glutamine, 1% chicken embryo, 100 U/mL penicillin, and100 μg/mL streptomycin).

Glucose Uptake

For long-term effect evaluation, the day before glucose uptake assay,cells are incubated in DMEM 5.5 mM D-glucose supplemented with 10% horseserum, 2% SVF, 1% chicken embryo, and 2% glutamine in the presence ofthe tested molecules for 16 h. The day after, and prior to the test,cells are washed and incubated in the presence of the tested moleculesfor 4 h more, in a serum-free medium (DMEM) containing 5.5 mM D-glucose.

For short-term effect evaluation, 4 hours prior to the glucose test,cells are washed and incubated in a serum-free medium (DMEM) containing5.5 mM D-glucose and the tested molecules. Then glucose uptake ismeasured by incubation of the cells for 5-10 min with radiolabeled2-deoxy-D-[1,2³H] glucose in Krebs-Ringer HEPES buffer (KRBH; pH 7.4),0.1% Bovine Serum Albumin (BSA), and fraction V (Sigma, A-4503). Glucoseuptake is arrested by two washing steps in ice-cold NaCl 0.9%. Thencells are solubilized in 0.1N NaOH for 30 min. Cell-associatedradioactivity is then counted and protein quantification is determinedusing the colorimetric Lowry method. Glucose uptake is estimated bymeasuring the radioactivity incorporated to the cells by a MicroBetacounter after adding 600 μL per well of scintillant (OptiphaseSuperMix3).

Protein quantification is performed by a colorimetric assay derived fromthe Lowry method.

Results are expressed in nmol glucose incorporated/5 mn/mg protein andin % of control or basal condition (100%).

Results

Drugs of the invention, tested alone, can enhance glucose uptake inmuscle cells. For example, FIGS. 4, 5 and 6 show that the glucose uptakeby H-2 Kb muscle cells is significantly enhanced after short-termincubation with acamprosate (0.1 μM, +45%) and almitrine (1 μM, +80%) orafter long-term incubation by nicergoline (10 μM, +28%), respectively,when compared to non-treated muscle cells.

1.3.2 Glucose Uptake in Human Diabetic Myotube Primary Cultures

In order to have a model that is most reflective of diabeticpathological conditions, the efficiency of drugs in enhancing glucoseuptake in diabetic myotubes was tested. Indeed, it has been demonstratedthat the diabetic phenotype is conserved in myotubes established fromdiabetic subjects.

Cell Culture and Media

The myotubes from a diabetic patient were grown on HAM's F10-based media(Sigma, ref. N6908) supplemented with 15% of fetal bovine serum, 1 mMglutamine.

Myoblasts were seeded at 380,000 cells/well in 12-well plates. After 2days of proliferation, the cells were placed in reduced serum conditions(2% horse serum) to induce differentiation. The myotubes were used after5 days of differentiation.

Dulbecco's modified Eagle's medium (DMEM)-based media (Gibco, ref.31053-028) supplemented with 2% heat-inactivated horse serum, 2%Glutamax (Gibco, ref. 35050) and washed for glucose uptake assays.Compounds were dissolved in DMSO to reach the desired finalconcentration prior to use.

The differentiated myotubes were treated for 24 h with the compositionsof the invention before the assay.

Glucose Uptake Assay

Before the initiation of glucose uptake, the cells were deprived ofserum and glucose. A deprivation was first performed in DMEM mediacontaining reduced glucose (1 g/L) and no serum. After adding thecompounds at the desired concentrations, the cells were incubated at 37°C. during 2 h30. The control with insulin allows the measurement ofglucose uptake induction through the insulin pathway. Insulin treatment(100 nM) was done during 30 min at 37° C. A subsequent glucose and serumdeprivation was performed in HBS buffer at 37° C. for 2 hours. The cellswere treated with a mixture of 2-[³H]deoxyglucose 10Ci/mM+2-deoxy-D-glucose at 10 μM for 30 min. The cells were rinsed twicewith 1 mL of cold PBS. The lysis was performed in 500 μL of 0.05N NaOHfor 20 minutes. The cell lysates were transferred into scintillationvials for the measurement of radioactivity with a MicroBeta counter.

Results

Compositions of the invention can enhance glucose uptake in humanprimary myotubes. For example, FIGS. 13, 14, 15, 16 and 17 show that theglucose uptake in diabetic myotubes is improved after pre-incubation bytorasemide (+24%, 18% respectively at 0.01 μM and 0.1 μM p<0.01 and +14%at 1 μM p<0.05), fenspiride (+34%, +30%, respectively at 0.01 μM and 0.1μM p<0.01 and +27% at 1 μM, p<0.05), tolfenamic acid (+13%, +13% and+12%, respectively at 0.01 μM, 0.1 μM and 1 μM, p<0.05), ifenprodil(+48% at 0.01 μM, p=0.07 and improvement at 0.1 μM and 1 μM) andtriamterene (0.01 μM, +13%, p<0.05).

1.3.3 Glucose Uptake in 3T3-L1 Adipocyte Cells

3T3-L1 cells are fibroblasts which, under appropriate conditions,differentiate into adipocyte-like cells. These cells are used to showthat compositions of the invention increase the glucose uptake inadipocytes, when compared to controls.

Cell Culture and Differentiation

3T3-L1 preadipocyte cells were cultured in DMEM containing 1%penicillin-streptomycin (PS) and 10% bovine calf serum at 37° C. in a 5%CO₂ atmosphere. To induce differentiation, 2-day post-confluentpreadipocytes were cultured in MDI differentiation medium I (DMEMcontaining 1% PS, 10% FBS, 0.5 mM IBMX, 1 μM dexamethasone, 0.5 μg/mLinsulin) for 2 days. Differentiation, as measured by the expression ofadipogenic markers and the appearance of lipid droplets, usually reachescompletion between days 4 and 8.

Glucose Uptake Activity Assay

Glucose uptake activity was analyzed by measuring the uptake ofradiolabeled glucose.

Differentiated 3T3-L1 adipocytes grown in 12-well plates were washedtwice with serum-free DMEM and incubated for 2 h at 37° C. with 1 mLDMEM containing 0.1% BSA. The cells were washed three times withKrebs-Ringer-HEPES (KRH) buffer (20 mM HEPES, pH 7.4, 136 mM NaCl, 4.7mM KCl, 1.25 mM MgSO₄, 1.25 mM CaCl₂, and 2 mg/mL bovine serum albumin),and incubated at 37° C. for 30 min with 0.9 mL of KRH buffer.

Next, cells were incubated with or without drugs for different durationsin order to evaluate their short-term and long-term effects.

To evaluate their short-term effect, cells were incubated with drugs ofthe invention for 4 hours at 37° C. To evaluate the long-term effect ofdrugs of the invention, the day prior to the test, cells werepre-incubated with or without drugs for 16 h. The day after, prior tothe test, cells were washed and incubated in the presence of the testedmolecules for 4 h more.

Glucose uptake was initiated by the addition of 0.1 mL of KRH buffercontaining 2-deoxy-D-[³H] glucose (37 MBq/L) and glucose (1 mM). After20 min, glucose uptake was terminated by washing the cells three timeswith cold PBS. The cells were lysed through incubation for 20 min at 37°C. with 0.7 mL of Triton X-100. Level of radioactivity in the celllysates was determined using a scintillation counter.

Protein quantification was performed by a colorimetric assay derivedfrom the Lowry method.

Results are expressed in nmol glucose incorporated/5 mn/mg protein andin % of control or basal condition (100%).

Results

Drugs of the invention can enhance glucose uptake in adipocytes. Forexample, FIGS. 7, 12 and 8 show that the glucose uptake bydifferentiated 3T3-L1 adipocyte cells can be enhanced after short-termincubation by carbetapentane (0.1 μM, +58%) and piribedil (10 nM, +68%)or after long-term incubation by almitrine (1 μM, +69%), respectively.

1.3.4 Glucose Uptake in TNFα-Induced Insulin Resistant 3T3-L1Differentiated Adipocytes

To evaluate the capacities of drugs of the invention, or combinationthereof, to improve glucose uptake by adipocytes in insulin resistantconditions, cells were pretreated by TNF-α. Upon TNF-α exposure, adecrease in glucose uptake in response to insulin is expected. Bycontrast, an increase in glucose uptake in response to insulin isexpected after treatment of the 3T3-L1 cells with TNF-α andacetylsalicylic acid (positive control).

Cell Culture and Differentiation

3T3L1 fibroblasts were maintained in DMEM 4.5 g/L glucose supplementedwith 5% calf serum donor, 5% newborn calf serum, 100 U/mL penicillin,and 100 μg/mL streptomycin at 37° C. under a 10% CO₂ atmosphere. Cellswere grown on 24-well plates at a density of 2560 cells/well in 0.5 mLof growth medium (DMEM 4.5 g/L glucose supplemented with 10% FCS, 100U/mL penicillin, and 100 μg/mL streptomycin). Five days after plating(90% of confluence), the induction of adipocyte differentiation wascarried out in DMEM 4.5 g/L glucose containing 10% FBS, 100 μM IBMX,0.25 μM dexamethasone and 170 nM insulin. Two days after, the inductionmedium was removed and changed by DMEM 4.5 g/L glucose containing 10%FBS and insulin 170 nM. Fresh media were replaced after two days. Threedays after, the adipocytes were incubated overnight in fasting medium(DMEM 4.5 g/L glucose containing 0.2 SVF, 100 U/mL penicillin, and 100μg/mL streptomycin. Then the cells were treated with H₂O or 5 ng/mL ofrat TNF-α (Peprotech, 400-14) for 48 h in DMEM 4.5 g/L glucosecontaining 10% FBS. The medium was refreshed every day. Glucose uptakewas assayed in different conditions: the adipocytes were treated for thenext 24 h with 0.1% DMSO with or without 5 ng/mL TNF-α, or with 5 ng/mLTNF-α and 5 mM acetylsalicylic acid, or with 5 ng/mL TNF-α and 100 nMinsulin, or the tested compounds with 5 ng/mL TNF-α in the presence orabsence of insulin (100 nM) as described below.

Glucose Uptake Activity Assay

Glucose uptake was measured by quantification of incorporatedradiolabeled glucose, after an incubation step with 2-deoxy-D[1,2³H]glucose for 5 min. Glucose uptake was arrested by two washing steps inice-cold PBS 1×, then were solubilized in 0.1N NaOH for 30 min.Cell-associated radioactivity was then counted using a MicroBeta counterafter adding 600 μL per well of scintillant (Optiphase SuperMix3).

In parallel, protein quantification was determined by a colorimetricassay derived from the Lowry method. Results are expressed in nmol ofglucose incorporated/5 mn/mg of protein and in % of control or basalcondition (100%).

To assess cell viability, an LDH activity measurement was performed onthe supernatants by using a UV method with a commercial kit (ABS PentraLDH IFCC CP, ref. A11A01871). Very briefly, LDH reduces NAD⁺ to NADH byoxidation of lactate to pyruvate. The NADH produced was evaluated bymeasurement of the absorbance at 340 nm. The amount of NADH produced isproportional to the amount of LDH released in the culture medium as aresult of cytotoxicity. Cell viability results are expressed in % ofcontrol or basal condition (100%).

Results

Drugs of the invention, tested alone, enhance glucose uptake inadipocytes in insulin resistance-mimicking conditions. For example,FIGS. 18, 19, 20 and 21 show that the glucose uptake by TNF-α-inducedinsulin-resistant 3T3-L1 adipocytes is significantly enhanced afterlong-term incubation by torasemide (+121% at 0.37 nM, p<0.05; +123% and+129%, respectively at 1 nM and 3.3 nM, p<0.01), ifenprodil (+140% at 1μM, p<0.01 and improvement at 10 nM and 100 nM, not shown), fenspiride(+130% at 1 nM, p<0.01 and improvement at 0.37 nM and 3.3 nM, not shown)and tolfenamic acid (+127% at 10 nM, p<0.01 and improvement at 100 nMand 1 μM, not shown).

At concentrations for which no significant improvement is observed whenused alone, drugs of the invention provide, upon their combined use, asignificant improvement in glucose uptake. As exemplified forcombinations of fenspiride with ifenprodil, triamterene or tolfenamicacid, and the combination of ifenprodil and tolfenamic acid, in FIGS.24-27, respectively, the improvement significantly rises up to +124%when compared to insulin-resistant non-treated cells for drugconcentrations as low as the nanomolar range.

Ifenprodil and fenspiride were also found to exert a significantenhancing effect on metformin treatment, a common antidiabetic, leadingto an improvement of glucose uptake of 126% and 136%, where each of thedrugs when used alone does not lead to any significant improvement(FIGS. 28 and 29). In spite of the use of sub-therapeutic doses ofmetformin, its combinations with fenspiride and ifenprodil result in asignificant improvement of glucose uptake. Hence, using such doses ofanti-diabetic chronic treatments with the compounds of the inventionallows to expect to alleviate or to delay the side effects usuallyobserved for these treatments.

Results of section 1.3 show that drugs of the invention are efficient inimproving glucose uptake in normal muscle cells and adipocytes as wellas in insulin resistance-mimicking conditions.

1.4 Glucose Production by Hepatic Cells

Cell Culture and Differentiation

Hepatocytes are isolated from 24 h-fasted male Wistar rats (200-250 gbody weight) by ex situ liver perfusion in the presence of collagenase.Cell viability is validated by a trypan blue exclusion test. Then cellsare suspended in Williams' medium supplemented with insulin and seededonto six-well plates (8×10⁵ cells/well) and incubated at 37° C. in ahumidified atmosphere of 95% air/5% CO₂. After plating, the medium isremoved and cells are cultured for 16 h in RPMI medium without glucose(supplemented with the tested drugs for long-term evaluation). Thefollowing day, hepatic glucose production is assessed in Krebs-RingerBicarbonate HEPES buffer (KRBH; pH 7.4) in the presence of theneoglucogenic substrates (lactate 10 mM and pyruvate 1 mM) and thetested molecules for 4 h (short-term).

Glucose Quantification

Supernatants are collected and glucose concentrations are determinedusing a glucose oxidase kit (Instrumentation Laboratory 0018250840). Inparallel, protein quantification is performed using the colorimetricLowry method.

Results are expressed in nmol glucose/mg protein and % of controlcondition (KLP: KRBH containing lactate and pyruvate).

Results

Drugs of the invention, tested alone, can lower glucose production byhepatic cells. For example, FIGS. 9, 10 and 11 show that the glucoseproduction by hepatocytes is significantly reduced after short-termtreatment by D-mannose (10 μM, −22%) or after long-term treatment byifenprodil (0.01 μM, −22%) or azelastine (10 μM, −36%).

1.5 Isolated Organs

1.5.1 Insulin and Glucagon Secretion in Isolated Islets of Langerhans

Isolated islets incubated with a range of glucose concentrations show adose-dependent pattern of insulin release. Thus, the use of isolatedislets is a physiological way of investigating the effects of candidatecompounds as initiators and potentiators of insulin secretion.

Tissue Preparation

Rats are anesthetized by intra-peritoneal (ip) injection ofketamine/xylasine. The peritoneal cavity is exposed and the pancreaticmain duct to the intestine is clamped. The pancreas is then cannulatedvia the common bile duct, distended with collagenase and removed. Isletsare extracted, washed and passed through a sterile stainless steelscreen before being centrifuged. Islets are then cleaned and placed intoCMRL medium containing 2 mM glutamine, 10% fetal bovine serum and 1%antibiotic/antimycotic solution and put into a 37° C. culture chambercontaining 5% CO₂.

Islet Perfusion

Islets are preincubated for 90 min in RPMI 1640 medium containing 10%FBS and 3 mM glucose at 37° C. with 5% CO₂. The islets of control andtreated groups are then incubated in the glucose perfusion system with aconstant flow rate (500 μL/mn) at 37° C. for 90 min. They are placed for30 min in the basal conditions (3 mM glucose), for 30 min in ahigh-glucose concentrated (20 mM) medium and finally for 30 min back inthe basal conditions (3 mM glucose). Throughout the perfusion, samplesof medium are collected from the output fraction and frozen at −80° C.At the end of the perfusion, the islets are harvested and frozen at −80°C. The total protein in the islets is extracted by acid ethanol (0.18 MHCl in 95% ethanol). Quantifications of the intracellular or releasedinsulin and glucagon in the collected output fractions are realized byELISA.

1.5.2 Glucose Uptake in Isolated Muscles

Muscle Incubation Procedure

Excised epitrochlearis are incubated at 29° C. for 50 min in 3 mL ofcontinuously gassed (95% O₂, 5% CO₂) preincubation medium, consisting ofKrebs-Henseleit bicarbonate buffer (KHB), 8 mM glucose, 32 mM mannitoland 0.1% bovine serum albumin (BSA). Following the preincubation, themuscle is transferred to another vial and incubated at 29° C. for 10 minin 3 mL of continuously gassed wash-out medium, consisting of KHB, 2 mMpyruvate, 38 mM mannitol and 0.1% BSA.

Finally, the muscle is incubated at 29° C. for 20 min in 3 mL of uptakemedium, which consists of KHB, 2 mM pyruvate, 6 mM glucose, 32 mMmannitol, and 0.1% BSA, with or without 280 μCi/mmol [³H] 2-deoxyglucose(2-DG) and 10 μCi/mmol [¹⁴C]-mannitol, and the designated treatment.

Immediately after incubation, muscles are briefly blotted on gauzewetted with 0.9% saline solution and freeze-clamped in liquid nitrogen.

Muscle Glucose Uptake Measurements

Glucose uptake is calculated from the incorporation rate of 2-DG intothe muscle fibers during the 20 min of incubation in the uptake medium.Frozen muscle samples are digested in 1 mL 1M KOH at 60° C. for 20 min.Muscle homogenates are neutralized with 1 mL 1 M HCl and 300 μL areadded in a scintillation cocktail. Duplicate samples are counted for ³Hand ¹⁴C in an LS-6000 liquid scintillation spectrophotometer.

Muscle 2-DG uptake is calculated as the difference between total muscle2-DG and 2-DG in the extracellular space. 2-DG concentration in theextracellular space is determined by the amount of [¹⁴C]-mannitol in thetissue.

1.5.3 Glucose Production from Isolated Perfused Liver

The isolated perfused rat model allows studying direct effects on theintact organ without the influence from extra-hepatic hormones and othersystemic alterations of metabolic fluxes.

Preparation of Tissue

Rats are anesthetized by ip injection of thiopental (50 mg/kg).Hemoglobin-free, non-recirculating perfusion is performed. Aftercannulation of the portal and cava veins, the liver is positioned in aplexiglass chamber. The perfusion fluid is Krebs/Henseleit bicarbonatebuffer (pH 7.4), saturated with a mixture of oxygen and carbon dioxide(95:5) by means of a membrane oxygenator with simultaneous temperatureadjustment at 37° C. The flow, provided by a peristaltic pump, isbetween 30 and 33 mL/mn. Candidate compounds or vehicles are added tothe perfusion fluid after having supplemented the Krebs/Henseleitbicarbonate buffer with fatty acid-free bovine serum albumin to ensurefull dissolution of the drugs. For all concentrations of the drugs themolar albumin/drug ratio was equal to 2.4.

The cell viability of the perfused liver is judged from both the oxygenuptake rates and the perfusion fluid leakage from its surface. Thelivers are discarded when the oxygen uptake dropped to 0.7 μmol min⁻¹g⁻¹ or when the surface fluid leakage surpassed 2.5% of the portal flow.Samples of the effluent perfusion fluid are collected and analyzed fortheir metabolite contents. The following compounds are assayed by meansof standard enzymatic procedures: glucose, lactate and pyruvate. Theoxygen concentration in the outflowing perfusate is monitoredcontinuously, employing a Teflon-shielded platinum electrode adequatelypositioned in a plexiglass chamber at the exit of the perfusate.Metabolic rates are calculated from input-output differences and thetotal flow rates and are referred to as the wet weight of the liver.

1.6 Results Synthesis

Table 4 gathers results that were obtained in all previously describedmodels (see sections 1.1 to 1.5 above). A value is attributed to eachcandidate compound depending on its effect in the different in vitromodels compared to vehicle. Results are normalized and weighed in orderto generate a relative performance value for each candidate compound. Ahigh value reflects a high potential of the compound for thenormalization of glucose levels and thus a significant efficacy forcontrolling glucose levels and/or for the treatment of diabetes orrelated disorders.

TABLE 4 Drug Name Relative performance value acamprosate 15 almitrine 38azelastine 30 baclofen 16 carbetapentane 33 cimetidine 31 cinacalcet 32dexbromopheniramine 21 diethylcarbamazine 32 diprophylline 11 D-mannose18 idebenone 53 ifenprodil 28 levosimendan 20 mexiletine 10 nicergoline40 piribedil 24 tolfenamic acid 9 tolperisone 19 torasemide 16triamterene 18 rilmenidine 16

The efficacy of drug combinations of the invention is also assessed inthe above in vitro models. The protocol used in these assays is the sameas described in section 1 above. The drug combinations listed in Table 5below show a particularly high relative performance value (determined asabove).

Results

All the drug combinations detailed in Table 5 led to a global positiveeffect for the normalization of blood glucose levels, and are thusconsidered efficient in the treatment of diabetes.

TABLE 5 Drug combinations with a high relative value Efficacy indiabetes ifenprodil and acamprosate + ifenprodil and baclofen + baclofenand acamprosate + mexiletine and cinacalcet + mexiletine andtorasemide + sulfisoxazole and torasemide + azelastine and nicergoline +idebenone and nicergoline + carbetapentane and nicergoline + almitrineand nicergoline + cimetidine and nicergoline + diethylcarbamazine andnicergoline + ifenprodil and nicergoline + azelastine and idebenone +acamprosate and nicergoline + azelastine and carbetapentane + azelastineand almitrine + idebenone and carbetapentane + idebenone and almitrine +triamterene and nicergoline + D-mannose and nicergoline + idebenone anddiethylcarbamazine + baclofen and D-mannose + baclofen and metformin +D-mannose and metformin + baclofen and D-mannose and metformin +ifenprodil and fenspiride + ifenprodil and torasemide + ifenprodil andtriamterene + ifenprodil and tolfenamic acid + fenspiride andtorasemide + fenspiride and triamterene + fenspiride and tolfenamicacid + torasemide and triamterene + torasemide and tolfenamic acid +triamterene and tolfenamic acid + metformin and ifenprodil andfenspiride + metformin and ifenprodil and torasemide + metformin andifenprodil and triamterene + metformin and ifenprodil and tolfenamicacid + metformin and fenspiride and torasemide + metformin andfenspiride and triamterene + metformin and fenspiride and tolfenamicacid + metformin and torasemide and triamterene + metformin andtorasemide and tolfenamic acid + metformin and triamterene andtolfenamic acid +

2. In Vivo Studies

2.1 Anti-inflammatory Effect of Combinations in Zucker Diabetic Fatty(ZDF) Rat Model

The efficacy of drug compositions of the invention comprising thecompound(s) of Tables 4 and 5 is confirmed in the Zucker Diabetic Fatty(ZDF) rat model. The Zucker Diabetic Fatty (ZDF) rat is an accuratemodel for type 2 diabetes based on impaired glucose tolerance caused bythe inherited obesity gene mutation which leads to insulin resistance.The fa mutation, which occurs in the ZDF rat, results in shortenedleptin receptor protein which does not effectively interact with leptin.This mutation is phenotypically expressed as obesity with high levels ofnormal leptin in the blood.

It is known that inflammation plays a role in the etiology of type 2diabetes and metabolic syndrome. Abnormally high plasmatic levels ofC-reactive protein (CRP) are associated with diabetes and metabolicsyndrome. ZDF rats have been used to study the effect of compositions ofthe invention on the inflammatory component of type 2 diabetes. ZDF ratsshow an increased level of plasmatic CRP.

Husbandry and Chronic Treatment

Rats were housed individually and kept at 22+/−2° C. on a 12-hlight/dark cycle. Animals had access to food (Purina 5008) and water adlibitum. While one group received the vehicle, the other groups weretreated with the candidate compounds listed in Tables 5 and 6 during 4weeks. Administrations were performed twice a day by oral route.

Blood Samples

Blood samples were taken from the topically anesthetized tails ofovernight-fasted rats in all groups.

Measurement of Plasma CRP Level

The CRP concentration in the plasma of all rats (lean rats, vehicle andbaclofen-acamprosate treated ZDF rats) were measured by an ELISA kitaccording to the manufacturer's recommendations (ref. CYT294 fromMillipore). The rat C-Reactive Protein (CRP) kit is a double polyclonalantibody sandwich enzyme immunoassay (EIA), which measures rat CRP.Standards, quality controls and samples of plasma were incubated for 30min in microtitration wells coated with polyclonal anti-rat CRPantibody. After a thorough wash, polyclonal anti-rat CRP antibodylabeled with horseradish peroxidase (HRP) was added to the wells andincubated for 30 minutes with the immobilized antibody-CRP complex.Following another washing step, the remaining HRP-conjugated antibodywas allowed to react with the substrate and tetramethylbenzidine (TMB).The reaction (5-10 min) was stopped by addition of an acidic solution,and absorbance of the resulting yellow color product was measuredspectrophotometrically at 450 nm. The absorbance is proportional to theconcentration of CRP. A standard curve was constructed by plottingabsorbance values versus CRP concentrations of standards, andconcentrations of unknown samples were determined using this standardcurve.

Results

Compositions of the invention are efficient in reducing CRPconcentration in the plasma of ZDF rats. For example, FIG. 22 shows thatthe CRP concentration is significantly reduced by acamprosate andbaclofen treatment (7.5 mg/kg and 0.5 mg/kg respectively) when comparedto vehicle-treated ZDF rats, and reaches the CRP level of lean rats.These results suggest a systemic anti-inflammatory effect ofcombinations of the invention.

2.2 Glucose Homeostasis Control in Db/Db Mice Model

The db/db mouse strain, deficient in leptin receptor, is a well-knownand characterized mouse model used to evaluate compounds targetingdiabetes. db/+ heterozygous mouse was used as control.

Acclimatization and Pre-Study Periods

85 mice (8 weeks old, 75 db/db and 10 db/+) were purchased from Janvier(France). Animals were housed in 28 ventilated cages (530 cm²×20 cm)throughout the experimental phase. Animals' beddings were renewed twicea week. Small devices were placed in the cages for enrichment ofenvironment (mouse houses and cellulose plugs). Mice were housed ingroups of 2 animals with a normal 12-hour light cycle (lights off at07:00 μm), 22±2° C. and 55±10% relative humidity. Mice had at least 14days of acclimatization during which they were fed with a standard R04chow diet (SAFE, Augy, France) and had free access to water.

After 12 days of acclimatization and 2 days (D0) before the beginning ofthe treatments, all mice were weighed and fasted for 6 hours from 08:00am to 02:00 μm. Subsequently, body weight has been measured daily allalong the study.

Blood (200 μL/EDTA) was collected from the retro bulbar sinus underisoflurane anesthesia. Plasma glucose and plasma insulin were quantifiedusing enzymatic and immune-enzymatic methods, respectively, in order torandomize animals in homogeneous groups.

At Day 0, just before the gavage, a drop of blood was collected from thetail vein to measure the non-fasted blood glucose using a glucometer(SmartCheck®).

Test Groups

Mice were allocated to groups according to their body weight and fastedblood glucose (N=8 mice/group):

-   -   Lean controls (db/+ mice) treated with vehicle (per os, twice        daily).    -   Obese negative controls (db/db mice) treated with vehicle (per        os, twice daily).    -   Obese positive controls (db/db mice) treated with metformin at        300 mg/kg (per os, once daily).    -   Obese animals (db/db mice) treated with compounds or        compositions of the invention.        Treatment

The treatment study duration was 6 weeks. Mice were treated twice dailyat 08:00 am and at 04:00 μm by gavage with vehicle, reference compoundor PXT compounds with respect to the following ratio: 10 mL/kg dosing(up to 20 mL/kg/day max).

Gavage volumes have been adjusted individually to the body weightrecorded in the morning.

During the treatment period, food and water consumption were monitoredand recorded. Food intake was measured and recorded daily (differencebetween two consecutive days). The mean food intake expressed as gramsof food consumed per animal per day were assigned to all the mice of theconsidered cage. Water intake was evaluated twice a week using the samemethod.

Once a week, at Days D7, D13, D21, D27, D35 and D41 just before thegavage, a drop of blood was collected from the tail vein to measure thenon-fasted blood glucose using a glucometer (SmartCheck®).

At Days D14, D28 and D42, food was removed at 08:00 am. Blood (200μL/EDTA) was collected from the retro bulbar sinus under anesthesia at02:00 μm (after 6 hours of fasting) to measure fasting plasma glucose.

Glucose Quantification

Plasma glucose concentration was determined by a colorimetric methodbased on enzymatic oxidation of glucose in the presence of glucoseoxidase. The produced hydrogen peroxide reacts with phenol and4-aminophenazone in a reaction catalyzed by peroxidase to form ared-violet quinoneimine dye as indicator. The intensity of the finalcolor is directly proportional to the glucose concentration and wasmeasured at 505 nm.

Results

Compositions of the invention reduce glycemia in the plasma of db/dbmice as soon as D28 of treatment (not shown). FIG. 23 shows that at D42,the glucose concentration is significantly reduced by administration ofa combination of D-mannose (5 mg/kg), (RS)-baclofen (6 mg/kg) andmetformin (150 mg/kg) when compared with vehicle-administered animals(p<0,001).

Noteworthily, the drugs, when used alone, do not induce any significantlowering of glycemia. More remarkably, compounds of the invention can beconsidered potent enhancers of currently known treatments for diabetes,thereby allowing the reduction of dosages and thus expecting a loweringof side effects.

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We claim:
 1. A method for treating diabetes or a related diseaseselected from impaired glucose tolerance, impaired fasting glucose,insulin resistance, metabolic syndrome, postprandial hyperglycemia andoverweight or obesity in a mammalian subject in need thereof, comprisingadministering to said mammalian subject an effective amount of acomposition comprising ifenprodil, or a salt, prodrug, or sustainedrelease formulation thereof in combination with at least one additionalcompound selected from (i) acamprosate, almitrine, amlexanox,azelastine, carbetapentane, cinacalcet, dexbromopheniramine,diethylcarbamazine, D-mannose, fexofenadine, mexiletine, tolperisone,torasemide, triamterene, tolfenamic acid, piribedil, levosimendan,cimetidine, diprophylline, idebenone and rilmenidine, or salt(s),prodrug(s) or sustained release formulation(s) thereof, and/or (ii) atleast one anti-diabetic agent.
 2. The method of claim 1, comprisingadministering to said mammalian subject a composition comprising atleast one of the following combinations of compounds: ifenprodil andacamprosate, ifenprodil and torasemide, ifenprodil and triamterene, orifenprodil and tolfenamic acid, or salt(s), prodrug(s), or sustainedrelease formulation(s) thereof.
 3. The method of claim 2, comprisingadministering to said mammalian subject a composition comprisingifenprodil and tolfenamic acid or salts(s), prodrug(s), or sustainedrelease formulations thereof.
 4. The method of claim 1, wherein the atleast one anti-diabetic agent is selected from acarbose, acetohexamide,alogliptin, berberine, bezafibrate, bromocriptine, buformin,carbutamide, chlorpropamide, chromium picolinate, ciprofibrate,clofibrate, colesevelam, dexfenfluramine, dutogliptin, exenatide,fenofibrate, gemfibrozil, gemigliptin, glibenclamide, glibornuride,glicetanile, gliclazide, glimepiride, glipizide, gliquidone, glisentide,glyclopyramide, imidapril, insulin, inulin, lipoic acid, linagliptin,liraglutide, mecobalamin, metformin, miglitol, mitiglinide, nateglinide,orlistat, phenformin, pioglitazone, pramlintide, repaglinide,rosiglitazone, saxagliptin, sitagliptin, tolazamide, tolbutamide,vildagliptin or voglibose, or salt(s), prodrug(s), or sustained releaseformulation(s) thereof.
 5. The method of claim 4, wherein the at leastone anti-diabetic agent is metformin, or a salt, prodrug, or sustainedrelease formulation thereof.
 6. The method of claim 5 comprisingadministering to said mammalian subject a composition comprising atleast one of the following combinations of compounds: ifenprodil andmetformin, ifenprodil and acamprosate and metformin, ifenprodil andtorasemide and metformin, ifenprodil and triamterene and metformin, orifenprodil and tolfenamic acid and metformin, or salt(s), prodrug(s) orsustained release formulation(s) thereof.
 7. A method for controllingblood glucose level in a mammalian subject in need thereof, comprisingadministering to said subject a composition comprising ifenprodil, or asalt, prodrug or sustained release formulation thereof in combinationwith at least one additional compound selected from acamprosate,almitrine, amlexanox, azelastine, carbetapentane, cinacalcet,dexbromopheniramine, diethylcarbamazine, D-mannose, fexofenadine,mexiletine, tolperisone, torasemide, triamterene, tolfenamic acid,piribedil, levosimendan, cimetidine, diprophylline, idebenone andrilmenidine, or salt(s), prodrug(s) or sustained release formulation(s)thereof.
 8. The method of claim 7, said method comprising administeringto said mammalian subject a composition comprising ifenprodil andtolfenamic acid or salts(s), prodrug(s), or sustained releaseformulations thereof.
 9. The method of claim 7, wherein the mammaliansubject is suffering from diabetes or from a related disorder selectedfrom impaired glucose tolerance, impaired fasting glucose, insulinresistance, metabolic syndrome, postprandial hyperglycemia andoverweight or obesity.
 10. A method for decreasing insulin resistance ina mammalian subject in need thereof, comprising administering to saidsubject a composition comprising ifenprodil, or a salt, prodrug orsustained release formulation thereof in combination with at least oneadditional compound selected from acamprosate, almitrine, amlexanox,azelastine, carbetapentane, cinacalcet, dexbromopheniramine,diethylcarbamazine, D-mannose, fexofenadine, mexiletine, tolperisone,torasemide, triamterene, tolfenamic acid, piribedil, levosimendan,cimetidine, diprophylline, idebenone and rilmenidine, or salt(s),prodrug(s) or sustained release formulation(s) thereof.
 11. The methodof claim 10, said method comprising administering to said mammaliansubject a composition comprising ifenprodil and tolfenamic acid orsalts(s), prodrug(s), or sustained release formulations thereof.
 12. Amethod for increasing or stimulating glucose uptake in adipocytes and/ormuscular cells in a mammalian subject in need thereof, comprisingadministering to said subject a composition comprising ifenprodil, or asalt, prodrug or sustained release formulation thereof in combinationwith at least one additional compound selected from acamprosate,almitrine, amlexanox, azelastine, carbetapentane, cinacalcet,dexbromopheniramine, diethylcarbamazine, D-mannose, fexofenadine,mexiletine, tolperisone, torasemide, triamterene, tolfenamic acid,piribedil, levosimendan, cimetidine, diprophylline, idebenone andrilmenidine, or salt(s), prodrug(s) or sustained release formulation(s)thereof.
 13. The method of claim 12, said method comprisingadministering to said mammalian subject a composition comprisingifenprodil and tolfenamic acid or salts(s), prodrug(s), or sustainedrelease formulations thereof.
 14. A method for decreasing apoptosis ofpancreatic beta cells in a mammalian subject in need thereof, comprisingadministering to said subject a composition comprising ifenprodil, or asalt, prodrug or sustained release formulation thereof in combinationwith at least one additional compound selected from acamprosate,almitrine, amlexanox, azelastine, carbetapentane, cinacalcet,dexbrornopheniramine, diethylcarbamazine, D-mannose, fexofenadine,mexiletine, tolperisone, torasemide, triamterene, tolfenamic acid,piribedil, levosimendan, cimetidine, diprophylline, idebenone andrilmenidine, or salt(s), prodrug(s) or sustained release formulation(s)thereof.
 15. The method of claim 14, said method comprisingadministering to said mammalian subject a composition comprisingifenprodil and tolfenamic acid or salts(s), prodrug(s), or sustainedrelease formulations thereof.
 16. The method of claim 1, wherein themammalian subject is suffering from type 2 diabetes.
 17. The method ofclaim 1, wherein the compound(s) is/are administered with apharmaceutically acceptable carrier or excipient.
 18. The method ofclaim 1, wherein the compounds are formulated or administered together,separately or sequentially.
 19. The method of claim 1, wherein thecomposition is administered repeatedly to said mammalian subject.